^BERKELEY  \ 

LIBRARY 

UNlVERSrTYOF 
k        CAUFORNIA     J 

S'osclances  Natural 
resources  Library 


THE   CARE   AND   TREATMENT  OF   MENTAL 

DISEASES  AND  WAR  NEUROSES  ("SHELL 

SHOCK")  IN  THE  BRITISH  ARMY 


THOMAS  W.  SALMON,  M.  D. 

MAJOR,  MEDICAL  OFFICERS'  RESERVE  CORPS 
UNITED  STATES  ARMY 


PUBLISHED  BY 

WAR  WORK  COMMITTEE 

OF 

THE  NATIONAL  COMMITTEE  FOR  MENTAL  HYGIENE,  Inc. 

50  UNION  SQUARE,  NEW  YORK  CITY 

1917 


'I) 


'U)S5f 


CONTENTS 

Page 

INTRODUCTION 

Acknowledgments 7 

Scope  of  Report ^ 

I.    MENTAL  DISEASES   (INSANITY) 

Prevalence   13 

Treatment 15 

Clinical  Types  of  Mental  Disease  among  Soldiers 18 

Outlook  in  Mental  Cases 22 

Summary 22 

II.  WAR  NEUROSES   ("SHELL  SHOCK") 

Prevalence 32 

Treatment 34 

Outcome 40 

Medico-legal  Relations 42 

III.  RECOMMENDATIONS  FOR  THE  UNITED  STATES  ARMY 

Summary  of  Recommendations  for  the  Care  and  Treatment 
of  Mental  Diseases  and  War  Neuroses  ("Shell  Shock") 

in  the  Expeditionary  Forces 48 

Expeditionary  Forces — Overseas 49 

Personnel  for  Special  Base  Hospital  for  Neuro-Psychiatric 

Cases 54 

Expeditionary  Forces — ^In  the  United  States 59 

Non-expeditionary  Forces 64 

APPENDICES 

I.     References  in  English  to  Mental  Diseases  and  War  Neuroses 

("Shell  Shock")  and  Their  Treatment  and  Management     69 
II.     The  Use  of  Institutions  for  the  Insane  as  Military  Hospitals     81 

III.  Special  Military  Hospitals  for  Mental  Diseases  and  War 

Neuroses  ("Shell  Shock")  in  Great  Britain  and  Ireland     93 

IV.  Facilities  Needed  for  Efficient  Treatment  of  Mental  Dis- 

eases in  a  Modern  Public  Institution 101 


38180.; 


INTRODUCTION 


THE  CARE  AND  TREATMENT  OF  MENTAL  DIS- 
EASES AND  WAR  NEUROSES  ("SHELL 
SHOCK")  IN  THE  BRITISH  ARMY 

INTRODUCTION 

NO  medico-military  problems  of  the  war  are  more  striking  than  those 
growing  out  of  the  extraordinary  incidence  of  mental  and  func- 
tional nervous  diseases  ("shell  shock").  Together  these  disorders  are 
responsible  for  not  less  than  one  seventh  of  all  discharges  for  disability 
from  the  British  Army,  or  one  third  if  discharges  for  wounds  are  ex- 
cluded. A  medical  service  newly  confronted  like  ours  with  the  task  of 
caring  for  the  sick  and  wounded  of  a  large  army  cannot  ignore  such  im- 
portant causes  of  invalidism.  By  their  very  nature,  moreover,  these 
diseases  endanger  the  morale  and  discipline  of  troops  in  a  special  way 
and  require  attention  for  purely  military  reasons.  In  order  that  as 
many  men  as  possible  may  be  returned  to  the  colors  or  sent  into  civil  life 
free  from  disabilities  which  will  incapacitate  them  for  work  and  self- 
support,  it  is  highly  desirable  to  make  use  of  all  available  information 
as  to  the  nature  of  these  diseases  among  soldiers  in  the  armies  of  our 
allies  and  as  to  their  treatment  at  the  front,  at  the  bases  and  at  the 
centers  established  in  home  territory  for  their  "reconstruction." 

England  has  had  three  years'  experience  in  dealing  with  the  medical 
problems  of  war.  During  that  time  opinion  has  matured  as  to  the 
nature,  causes  and  treatment  of  the  psychoses  and  neuroses  which  pre- 
vail so  extensively  among  troops.  A  sufficient  number  of  different 
methods  of  military  management  have  been  tried  to  make  it  possible  to 
judge  of  their  relative  merits.  INIy  visit  to  England  was  for  the  piu-pose 
of  observing  these  matters  at  first  hand  so  that  I  might  contribute  infor- 
mation which  might  aid  in  formulating  plans  for  dealing  with  mental 
and  nervous  diseases  among  our  own  forces  when  they  are  exposed  to  the 
terrific  stress  of  modern  war. 

Acknowledgments 

I  wish,  at  the  outset,  to  record  my  appreciation  of  the  many  courtesies 
which  enabled  me  to  use  the  limited  time  at  my  disposal  to  the  best 
advantage.  The  Army  Council,  upon  the  request  of  Ambassador  Page, 
agreed  to  place  at  ray  disposal  every  facility  for  studying  mental  and 
nervous  diseases.  The  medical  officers  of  the  special  hospitals  for  mental 
and  nervous  cases,  through  the  courtesy  of  Sir  Alfred  Keogh,  Director 
General  of  the  Royal  Army  Medical  Corps,  gave  me  opportunities  to 

7 


8  MENTAL  DISEASES  AND  WAR  NEUROSES 

observe  the  work  of  the  institutions  under  their  charge.  Others  actively 
engaged  in  deahng  with  various  administrative  and  cHnical  phases  of 
these  problems  not  only  gave  me  valuable  information  but  very  kindly 
offered  suggestions  as  to  practical  means  by  which  our  army  might  profit 
by  the  experience  of  British  medical  officers.  I  would  mention  especially 
Lt.  Colonel  William  Aldren  Turner,  the  principal  advisor  to  the  govern- 
ment in  these  matters;  Lt.  Colonel  Sir  John  Collie,  President  of  the  Special 
Pension  Board  on  Neurasthenics;  Sir  AVilliam  Osier,  under  whose  direc- 
tion work  is  carried  on  in  the  special  hospital  for  functional  disorders  of 
the  heart;  Dr.  C.  Herbert  Bond  of  the  Board  of  Control;  Dr.  Henry 
Head,  who  represented  the  Medical  Research  Committee  in  the  con- 
ference upon  nervous  diseases  among  soldiers,  held  in  Paris  in  April,  1916; 
Dr.  H.  Crichton  Brown  who  has  prepared  a  thoughtful  memorandum  on 
the  subject  for  the  War  Office;  Lt.  Colonel  Sir  Robert  Armstrong-Jones 
and  the  American  liaison  officers  in  London — Brigadier  General  Bradley 
and  Lt.  Colonel  Lyster  of  the  army  and  Surgeon  Pleadwell  of  the  navy. 
Dr.  William  Morley  Fletcher,  Secretary  of  the  Medical  Research  Com- 
mittee, which  from  an  early  period  in  the  war  has  directed  attention  to 
the  importance  of  nervous  diseases,  presented  me  with  a  motion  picture 
film  showing  some  of  the  more  common  symptoms  in  soldiers  suffering 
from  the  neuroses.  Dr.  John  T.  MacCurdy,  Associate  in  Psychiatry  at 
the  New  York  State  Psychiatric  Institute,  who  was  studying  the  war 
neuroses  in  special  hospitals  in  London,  very  kindly  visited  the  Moss 
Side  Military  Hospital  at  Maghull  and  the  Craiglockhart  Hospital  for 
officers,  near  Edinburgh,  and  furnished  me  with  reports  on  the  facilities 
for  treatment  at  these  institutions.* 

It  is  impossible  to  examine  closely  any  phase  of  the  work  of  caring 
for  disabled  soldiers  in  Great  Britain  without  being  profoundly  im- 
pressed with  the  high  degree  of  executive  and  scientific  skill  with  which 
the  unprecedented  medical  problems  of  the  war  have  been  met.  More 
than  twice  as  many  hospital  beds  have  been  provided  for  soldiers  and 
sailors  as  existed  in  the  whole  United  Kingdom  in  August,  1914,  for 
the  civil  population.  In  the  stress  of  war,  with  all  difficulties  im- 
mensely increased,  special  types  of  treatment  have  been  provided 
which  the  most  enlightened  civil  communities  had  not  yet  been  able 
to  supply  in  time  of  peace.  These  almost  incredible  achievements 
were  made  possible  by  the  patriotic  efforts  with  which  the  nation  dis- 
posed of  obstacles  in  every  direction.  Beneath  all  this  work  is  the 
deep  sympathy  which  officials  and  the  public  alike  bestow  upon  all 
those  returning  from  the  front  who  are  in  need  of  care  or  attention. 

•Appendix  III. 


INTRODUCTION  9 

Scope  of  Report 

I  have  omitted  entirely  from  this  report  any  account  of  the  treat- 
ment of  organic  nervous  diseases  and  of  injuries  to  the  central  nervous 
system  or  the  peripheral  nerves.  Organic  nervous  diseases  are  not 
especially  frequent  and  seem  to  present  no  special  military  problems. 
Injuries  of  the  central  nervous  system  are  frequent  and  severe.  Those 
that  do  not  prove  fatal  very  quickly  are  well  cared  for  at  first  in  gen- 
eral surgical  wards  where  the  services  of  neurologists  and  neurological 
surgeons  are  available  and  later  in  special  hospitals  or  special  hospital 
wards.  A  very  serious  difiiculty  in  dealing  with  destructive  brain  and 
cord  lesions  is  that  the  patients  sooner  or  later  pass  from  hospitals  in 
which  special  care  and  nursing  are  provided  to  their  homes  or  to  poorly 
equipped  auxiliary  hospitals  in  which  many  soon  get  worse  or  die. 
Injuries  to  the  peripheral  nerves  are  frequent  and  important,  in  fact 
there  are  few  extensive  injuries  to  the  extremities  in  which  important 
nerves  escape.  With  neurological  ad\ace,  the  surgeons  deal  with  these 
cases  successfully  in  the  base  hospitals  and  their  after-treatment  is  well 
carried  on  in  the  "reconstruction  centers"  for  orthopedic  cases. 
Neither  of  these  classes  of  injuries  concerns  us  especially  in  a  considera- 
tion of  the  treatment  and  military  management  of  mental  and  func- 
tional nervous  diseases,  except  for  the  fact  (to  be  commented  upon 
later)  that  the  treatment  of  the  war  neuroses  might  be  carried  out 
advantageously  in  home  territory  in  co-operation  with  orthopedic 
reconstruction  centers. 

Although  the  problems  presented  by  mental  and  functional  nervous 
diseases  have  many  clinical  and  administrative  features  in  common  and 
although  these  disorders  should  be  dealt  with  by  medical  officers  with  the 
same  kind  of  special  training,  it  seems  desirable  to  consider  their  treat- 
ment in  England  separately  in  this  report. 

My  observations  as  to  the  nature  of  the  neuroses  met  with  in  war  are 
based  partly  upon  a  study  of  the  very  extensive  literature  upon  this 
subject  which  has  come  into  existence  since  the  commencement  of  the 
war,*  but  chiefly  upon  personal  conversation  with  medical  men  engaged 
in  treating  these  cases  in  England.  It  is  almost  needless  to  say  that 
during  a  short  period  spent  largely  in  securing  information  regarding 
facilities  for  treatment  and  administrative  methods  of  management 
and  in  examining  special  hospitals  for  the  care  of  these  cases,  I  had 
no  opportunity  to  make  original  clinical  observations,  although  I  saw 
and  examined  superficially  many  cases  of  all  degrees  of  severity. 

*  Appendix  I. 


I.    MENTAL  DISEASES   (INSANITY) 


I.  MENTAL  DISEASES  (INSANITY) 
Prevalence 
"IVTILITARY  life  has  well  been  called  the  "touchstone  of  insan- 
-'■*-'-  ity"  on  account  of  the  high  prevalence  of  mental  diseases 
in  armies  even  during  peace.  Medical  statistics  of  the  present 
war  are  as  yet  untabulated  and  so  it  is  impossible  to  state  the 
rate  per  thousand  for  mental  diseases.  The  only  means  of 
estimating  their  incidence  is  by  considering  the  number  of  cases 
diagnosed  officially  as  "insane"  in  the  military  hospitals  at  a  given 
time.  On  March  31,  1917,  about  1.1  per  cent  of  all  patients  in 
military  hospitals  of  Great  Britain  were  officially  diagnosed  as 
insane.  The  percentage  among  expeditionary  patients  was  1.3 
and  among  non-expeditionary  patients  1.1.  The  enormous  prev- 
alence of  wounds  in  patients  from  the  expeditionary  troops  reduces 
the  percentage  of  all  other  conditions  and  so  the  excess  of  mental 
cases  among  expeditionary  cases  is  much  greater  than  is  apparent. 
Among  non-wounded  expeditionary  patients  the  percentage  was 
about  three  times  that  among  the  non-expeditionary  cases.  The 
rate  among  officers  was  only  one  third  that  among  men  in  expedi- 
tionary patients  and  about  the  same  in  non-expeditionary  patients. 
This  has  an  important  bearing  upon  the  fact  that  the  rate  for  the 
war  neuroses  ("shell  shock")  is  four  times  as  high  among  officers 
as  among  men.  About  6,000  patients  are  admitted  annually  from 
both  the  expeditionary  and  non-expeditionary  forces  to  the  special 
military  hospitals  for  the  insane.  As  one  such  hospital  with  a 
large  admission-rate  is  a  "clearing  hospital"  and  distributes  its 
patients  to  other  special  hospitals,  some  patients  are  obviously 
counted  twice  in  the  only  statistics  available.  To  offset  this  is 
the  fact  that  a  much  larger  number  of  mental  cases  do  not  go  to 
special  military  hospitals  at  all  but  are  discharged  to  friends,  with 
or  without  an  official  diagnosis  of  insanity,  or  are  sent  directly  to 
local  institutions  for  the  insane.  This  is  the  rule  in  the  case  of 
non-expeditionary  troops.  It  can  be  estimated,  from  all  the  data 
available,  that  the  annual  admission  rate  is  about  2  per  1,000 
among  the  non-expeditionary  troops  and  about  4  per  1,000  among 
expeditionary  troops.  The  rate  in  the  adult,  male,  civil  popula- 
tion of  Great  Britain  is  about  1  per  1,000. 

13 


14  MENTAL  DISEASES  AND  WAR  NEUROSES 

There  is  statistical  evidence^^'K  /■  eh  indicates  that  the  insanity 
rate  in  the  British  Army  is  less  at  the  present  time  than  it  was  in 
the  first  year  of  the  war,  and  that  it  has  not  reached  some  of  the 
high  rates  reported  in  recent  wars.     The  high  and  constantly 
increasing  rate  for  the  war  neuroses  suggests  that  the  latter  dis- 
orders are  taking  the  place  of  the  psychoses  in  modern  war.     How 
much  this  phenomenon  is  due  to  an  actual  change  in  incidence 
and  how  much  to  former  errors  in  diagnosis  cannot  be  stated 
accurately.     There  is  a  strong  suspicion  that  the  high  insanity 
rate  in  the  Spanish-American  War  and  the  Boer  War,  and  per- 
haps in  earlier  conflicts,  was  due,  in  part  at  least,  to  failure  to 
recognize  the  real  nature  of  the  severe  neuroses,  which  are  grouped 
under  the  term  "shell  shock"  in  this  war.     This  may  account 
for  the  remarkable  recovery  rate  among  insane  soldiers  in  other 
wars.     It  is  certain  that  in  the  early  months  of  the  present  war 
many  soldiers  suffering  from  war  neuroses  were  regarded  as  insane 
and  disposed  of  accordingly.     When  one  remembers  that  the 
striking  manifestations  seen  in  these  cases  are  unfamiliar  in  men 
to  physicians  in  general  practice,  it  is  not  surprising  that  some  of 
the  severer  disturbances  should  have  been  interpreted  as  signs  of 
insanity.     The  benign  course  and  rapid  recovery  of  many  of 
these  cases  upon  their  return  to  England,  together  with  increasing 
familiarity  with  the  symptoms  of  functional  nervous  diseases, 
soon  enabled  the  medical  officers  serving  with  troops  to  recognize 
their  real  nature.     Even  at  the  present  time,  however,  it  is  by 
no  means  rare  for  soldiers  with  functional  nervous  diseases  to  be 
sent  to  England  as  insane  or  for  insane  soldiers  to  be  sent  to 
hospitals  for  the  war  neuroses.     This  is  shown  by  the  records  of 
the  Red  Cross  Military  Hospital  at  Maghull,  a  hospital  for  the 
treatment  of  war  neuroses.     Since  this  hospital  was  opened,  ten 
per  cent  of  the  1,749  patients  admitted*  were  found  to  be  suffering 
from  mental  diseases  and  sent  to  hospitals  for  the  insane.     On  the 
other  hand,  twenty  per  cent  of  the  6,755  patients  received*  from 
France  since  the  commencement  of  the  war  at  "D  Block"  of  the 
Royal  Victoria  Hospital  at  Netley,  a  clearing  hospital  for  mental 
cases,  were  subsequently  sent  to  hospitals  for  functional  nervous 
diseases.     On  the  whole  it  may  be  said  that  medical  officers 
serving  with  troops  are  constantly  becoming  more  familiar  with 

*To  May  31,  1917. 


MENTAL  DISEASES  15 

the  symptoms  of  functional  nervous  diseases  and  that  fewer  such 
errors  now  occur. 

Treatment 

The  return  to  England  of  considerable  numbers  of  mental  cases, 
commencing  early  in  the  war  and  steadily  continuing,  soon  led 
to  rather  difficult  questions  as  to  their  disposal.  Before  the  war, 
the  army  maintained  a  small  department  for  the  insane  at  the 
Royal  Victoria  Hospital  at  Netley.  This  department,  which  is 
known  as  "D  Block"  and  constitutes  practically  an  independent 
unit,  accommodated  only  125  men  and  three  officers.  For  years 
the  annual  admission  rate  averaged  120.  The  only  cases  received 
were  soldiers  who  had  served  at  least  ten  years  in  the  regular  army 
or  those  with  shorter  service  whose  insanity  seemed  clearly  to  be 
due  to  such  causes  arising  in  line  of  duty  as  head  injuries,  tropical 
fevers,  exhaustion,  wounds,  etc.  As  it  was  manifestly  impossible 
to  care  for  more  cases  at  Netley,  the  insane  soldiers  who  were  first 
sent  home  from  the  expeditionary  forces,  as  well  as  those  from  the 
home  forces,  were  "certified"  (i.  e.,  legally  committed)  and  sent 
to  the  local  "county  lunatic  asylums"  as  they  are  called,  unless 
their  relatives  and  friends  took  them  off  the  hands  of  the  govern- 
ment and  disposed  of  them  otherwise.  The  appearance  of  soldiers 
from  the  front  in  the  district  asylums,  where  they  were  burdened 
by  the  double  stigma  of  lunacy  and  pauperism,  aroused  public 
disapproval  that  speedily  made  itself  felt  in  Parliament. 

About  this  time  arrangements  had  been  made  to  take  over 
one  county  or  borough  asylum  in  each  group  of  ten  in  the  United 
Kingdom  for  use  as  a  general  military  hospital  for  medical  and 
surgical  cases.*  This  made  it  possible  to  establish  special  war 
hospitals  for  mental  cases.  A  department  of  the  Middlesex 
County  Asylum  (re-named  the  Napsbury  War  Hospital),  was 
opened  for  mental  cases,  and  the  District  Asylum  at  Paisley, 
Scotland  (re-named  the  Dykebar  War  Hospital),  was  turned  over 
entirely  for  this  purpose  as  was  part  of  the  Lord  Derby  War  Hos- 
pital at  Warrington  which  had  been  the  Lancashire  Asylum. 
Later  the  Belfast  District  Asylum  in  Ireland  was  take  over  as 
the  Belfast  War  Hospital  and  still  more  recently  the  Perth  Dis- 
trict Asylum  was  taken  over  as  the  Murthley  War  Hospital,  both 

*Appendix  II. 


16  MENTAL  DISEASES  AND  WAR  NEUROSES 

being  used  entirely  for  the  insane.  A  pavilion  at  the  Richmond 
District  Asylum,  Ireland,  accommodates  100  and  a  small  hospital 
in  London  (Letchmere  House)  cares  for  about  84  officers.  An 
annex  in  connection  with  the  Dykebar  War  Hospital  has  recently 
been  opened  so  that  there  are  now  about  3,400  beds  in  strictly 
military  hospitals  available  in  Great  Britain  and  Ireland  for  in- 
sane soldiers. 

No  attempt  has  been  made  to  care  for  the  insane  in  France,  the 
policy  of  the  War  Office  being  to  send  all  cases  to  the  clearing  hos- 
pital at  Netley  and  then  to  the  special  institutions  named  as  soon 
as  possible.  There  are  available  in  France  only  125  beds,  all  for 
the  temporary  detention  of  mental  cases. 

Of  the  twenty-one  asylums  and  similar  institutions  in  Great 
Britain  and  Ireland  which  have  been  converted  into  military 
hospitals,*  three  are  used  wholly  or  in  part  for  functional  nervous 
diseases.  In  spite  of  the  fact  that  the  names  of  all  these  asylums 
were  changed  when  they  were  taken  over  for  their  new  use,  a  sus- 
picion apparently  exists  among  the  public  that  soldiers  with  men- 
tal or  nervous  diseases  are  still  being  sent  to  district  asylums  as 
"pauper  lunatics,"  the  official  designation  of  such  patients.  It 
is  not  easy  for  us  in  America  to  understand  the  importance  of  this 
aspect  of  the  question  for  in  most  states  our  state  hospitals  enjoy 
a  reputation  which  would  no  more  stigmatize  insane  soldiers  than 
it  does  their  sisters  or  daughters  when  they  require  treatment 
obtainable  only  in  these  institutions.  In  England,  however,  in- 
sanity and  pauperism  have  been  closely  linked  and  it  is  the  latter 
which  is  very  largely  responsible  for  the  stigma  attached  to  these 
institutions.  The  government  was  obliged,  therefore,  early  in 
1915  to  announce  that  it  had  adopted  the  policy  of  sending  to  the 
district  asylums  onlj'  the  following  groups  of  cases  from  the  expe- 
ditionary forces : 

1.  Patients  with  general  paralysis  of  the  insane. 

2.  Patients  with  chronic  epilepsy. 

3.  Patients  with  incurable  mental  diseases  and  those  giving  a  history  of  in- 
sanity before  enlistment. 

There  is  power  to  apply  the  pension  of  the  soldier  toward  his 
support  in  these  cases  and  he  is  thereby  prevented  from  coming 
"on  the  rates."     The   separation   allowances   are   discontinued 

•To  July  1, 1917. 


MENTAL  DISEASES  17 

when  the  pension  is  commenced.  All  insane  soldiers  from  the 
non-expeditionary  forces  are  certified  and  sent  to  the  district 
asylums  unless  it  can  be  shown  that  the  disease  was  caused  or 
aggravated  by  military  service. 

The  results  of  these  arrangements  are  not  wholly  satisfactory. 
There  is  a  strong  tendency  to  adopt  an  entirely  different  attitude 
toward  insane  soldiers  than  the  wonderfully  generous  one  which 
the  nation  has  adopted  toward  the  wounded  and  those  suffering 
from  physical  disease.  In  the  latter,  the  government  readily 
admits  its  responsibility  and  makes  liberal  provisions  for  treat- 
ment, pension  and  industrial  re-education,  while  in  the  former 
every  effort  is  made  to  place  the  burden  of  responsibility  and  of 
support  upon  the  patient  or  his  relatives  by  magnifying  alleged 
constitutional  tendencies  and  minimizing  the  effects  of  military 
service.  It  is  quite  apparent  that  the  conditions  of  actual  service 
have  much  to  do  with  the  development  of  mental  disease.  Even 
in  the  case  of  general  paralysis  of  the  insane  it  is  by  no  means 
certain  that  a  young  soldier  with  a  positive  Wassermann  test 
would  have  developed  general  paralysis  had  he  not  been  exposed 
to  the  supreme  ordeal  of  service  at  the  front.  This  official  attitude 
toward  mental  disease  results  in  an  average  period  of  treatment 
far  shorter  than  is  required  in  even  the  most  benign  psychoses  in 
civil  life.  It  is  evident  that  mental  cases  are  insufficiently  treated 
in  military  hospitals. 

During  1916,  the  number  of  mental  cases  passing  through  the 
3,400  beds  available  for  their  care  in  Great  Britain  and  Ireland 
was  about  6,000.  The  recovery  rate  in  military  cases  is  much 
higher  than  in  the  mental  cases  admitted  to  civil  hospitals  but 
the  rapid  movement  of  population  results  chiefly  from  the  custom 
of  "passing  on"  these  cases.  Insane  soldiers  of  the  non-expedi- 
tionary forces  are  sent  almost  invariably  directly  to  district 
asylums  from  general  hospitals  without  even  going  to  "D  Block" 
where  an  inquiry  could  be  made  by  experts  to  estimate  the  part 
played  by  military  service  in  the  causation  of  mental  illness. 
When  relatives  and  friends  are  induced  to  take  insane  soldiers 
from  the  military  hospitals  the  next  step  is  usually  admission  to 
the  district  asylums.  During  the  year  ending  May  31,  1917,  900 
insane  soldiers  were  admitted  to  the  local  asylums.  A  considerable 
proportion  of.  the  insane,  even  from  the  expeditionary  forces. 


18  MENTAL  DISEASES  AND   WAR  NEUROSES 

sooner  or  later  find  their  way  into  the  institutions  out  of  which 
Parliament  was  intent  upon  keeping  them. 

The  disposition  of  mental  cases  is  well  illustrated  by  the  follow- 
ing table  showing  what  was  done  in  the  case  of  5,-1.73  patients 
admitted  from  September  1,  1914,  to  May  31,  1917,  at  "D  Block," 
Netley — a  clearing  hospital  for  mental  diseases. 

DISPOSITION  OF  CASES  ADMITTED  TO  "D  BLOCK,"  NETLEY,  FROM  THE 
BEGINNING  OF  THE  WAR  TO  DECEMBER  31,  1916 

To  institutions  [or  the  insane 

Lord  Derby  War  Hospital,  Warrington 1,424 

Murthley  War  Hospital,  Perth 210 

Dykebar  War  Hospital,  Paisley 611 

Shomcliffe  (Canadian  Clearing  Mental  Hospital) 147 

District  Asylums 128 

Dartford  (for  insane  prisoners  of  war) 3 

To  war  hospitals  for  functional  nervous  cases 

Moss  Side  Hospital,  Maghull 509 

Springfield  War  Hospital,  London 680 

To  hospitals  for  organic  nervous  diseases  and  injuries 

Queens  Square 4 

Maida  Vale  (for  pensioners) 2 

To  Royal  Victoria  Military  Hospital,  Netley  (recoveries  and  nervous  diseases)  . .  1,007 

To  almshouses 2 

To  Canadian  hospitals  or  returned  to  Canada 5 

To  Australian  hospitals  or  returned  to  Australia 33 

To  other  hospitals  and  institutions 204 

Discharged  to  relatives  and  friends 258 

Died 21 

Furloughed , 110 

Returned  to  duty 58 

Remaining  in  hospital 57 

Total 5.473 

Clinical  Types  of  Mental  Disease  among  Soldiers 
Contrary  to  popular  belief  and  to  some  medical  reports  pub- 
lished early  in  the  war,  no  new  clinical  types  of  mental  disease 
have  been  seen  in  soldiers.  There  are  no  "  war  psychoses."  The 
clinical  pictures  familiar  in  civil  life  are  seen,  colored  often  by 
the  experience  at  the  front,  but  for  the  most  part  unchanged 
in  their  symptomatology,  outcome  and  course.  The  distribution 
of  the  different  psychoses  has  been  strikingly  different  from  that  in 
civil  life  but  this  has  been  chiefly  due  to  the  different  age  periods 
represented  in  patients  from  the  army.  The  absence  of  the 
organic  mental  diseases  of  the  later  decades  of  life — which  play  so 


MENTAL  DISEASES  19 

large  a  part  in  civil  statistics — has  resulted  in  abnormally  high 
percentages  for  other  psychoses.  Although  no  statistics  for  the 
whole  number  of  admissions  in  a  single  year  are  available,  nearly  a 
thousand  admissions  from  expeditionary  troops  to  the  Dyke- 
bar  War  Hospital  during  1916  have  been  tabulated  by  Major 
R.  D.  Hotchkis.* 

This  series  of  cases  is  large  enough  to  make  some  of  the  findings 
significant.  They  are  borne  out  by  observations  made  by  Capt 
David  K.  Henderson  at  the  Lord  Derby  War  Hospital  at  Warring- 
ton which  received  2,042  mental  cases  during  the  year  ending 
April  30,  1917. 

Mental  Deficiency.  About  eighteen  per  cent  of  the  patients  ad- 
mitted to  the  military  hospitals  for  mental  diseases  are  mentally 
defective.  Only  such  mental  defectives  as  get  into  trouble  or 
develop  acute  psychotic  episodes  of  one  sort  or  another  gain  ad- 
mission to  these  hospitals.  It  is  impossible,  therefore,  from  the 
point  of  view  of  the  hospitals  for  mental  diseases,  to  draw  any 
conclusions  as  to  the  relation  of  mental  deficiency  to  military 
service.  The  low  grade  of  many  cases  received  in  the  special 
hospitals  is  very  striking  and  shows  an  amazing  indifference  on 
the  part  of  recruiting  officers  to  this  type  of  disability.  It  is 
said  that  the  worst  types  got  in  during  the  first  rush  of  recruits 
under  the  voluntary  system  and  that,  since  then,  more  pains 
have  been  taken  to  exclude  them.  Of  the  151  mental  defectives 
admitted  to  the  Dykebar  War  Hospital,  37  were  sent  there 
simply  because  they  had  been  giving  trouble  to  other  hospitals 
where  they  had  been  treated  for  wounds  or  diseases.  Most 
of  these  soldiers  were  defectives  of  the  restless,  criminalistic 
type,  many  of  whom  had  been  civil  offenders  before  entering 
the  army.  It  is  believed  that  they  represent  but  a  small  part 
of  the  cases  of  this  type  in  the  military  service,  the  majority 
being  dealt  with  from  a  disciplinary  standpoint  without  regard 
to  the  existence  of  mental  defect,  thus  following  the  precedent 
which,  imfortunately,  is  so  firmly  established  in  civil  life.  The 
remaining  114  defectives  sent  to  Dykebar  had  been  able  to  earn 
their  own  livelihood  before  entering  the  amiy.  They  had  no 
criminalistic  traits  but  had  proved  quite  valueless  in  actual  fight- 
ing.    Sometimes   these   men  were  actually  dangerous  to  their 

*Appendix  I  (reference  No.  48). 


20  MENTAL  DISEASES  AND  WAR  NEUROSES 

comrades  and  were  permitted  to  load  their  rifles  only  when  an 
attack  was  made.  The  very  specialized  activities  of  modern 
fighting  discloses  such  individuals  who  under  former  military 
conditions  would  not  have  come  to  light.  It  is  said  that  in  the 
Boer  War  many  boys  from  the  special  classes  of  the  Birmingham 
and  London  schools  made  good  soldiers  but  apparently  the  mili- 
tary usefulness  of  the  mentally  defective  has  disappeared  under 
the  conditions  of  modern  warfare — an  exceedingly  important 
point  for  the  consideration  of  a  nation  engaged  in  raising  a  new 
army. 

Among  the  defectives  received  in  the  military  hospitals  for 
mental  cases  are  many  in  whom  attention  has  been  directed  to 
their  disability  by  episodes  of  confusion  or  excitement.  The 
outlook  is  very  favorable  in  such  cases,  the  quiet  routine  of  the 
hospital  having  a  beneficial  eifect  in  a  remarkably  short  period 
of  time.  Mental  defectives  develop  war  neuroses,  in  spite  of 
statements  to  the  contrary,  but  with  striking  infrequency.  The 
generally  high  standard  of  intelligence  among  the  patients  in  the 
"shell  shock"  hospitals  is  noticeable. 

There  is  much  difference  of  opinion  as  to  whether  or  not  men 
known  to  be  mentally  defective  should  be  recruited  for  any  mili- 
tary service.  In  favor  of  their  acceptance  it  is  said  that  they 
can  be  assigned  to  certain  kinds  of  work  at  the  bases  for  which 
they  are  particularly  fitted  and  thereby  release  soldiers  with  more 
intelUgence  for  duty  at  the  front.  When  one  remembers  that  not 
only  the  army  but  the  whole  nation  is  at  war,  it  seems  more 
advisable,  even  for  military  reasons,  to  leave  defectives  at  work 
in  an  environment  to  which  they  have  already  become  accus- 
tomed than  to  try  the  experiment  of  placing  them  even  in  a 
special  kind  of  military  service.  Certainly  the  army  now  has 
no  means  of  assigning  its  work  with  reference  to  the  limitations 
of  such  a  special  group.  Moreover,  when  the  army  knowingly 
accepts  mentally  defective  recruits,  it  assumes  a  liability  for  their 
protection  which  it  can  hardly  be  expected  to  meet  in  all  the 
exigencies  of  war.  Much  injustice  is  done  in  the  army  by  pun- 
ishing mental  defectives  for  military  offenses  which  would  have 
been  condoned  had  the  real  mental  condition  of  the  offenders 
been  appreciated.  There  are  sufficient  grounds  for  excluding  all 
mental  defectives  from  the  military  forces  except  when  the  last 


MENTAL  DISEASES  21 

available  man-power  must  be  utilized.  When  this  is  the  case  it 
will  doubtless  be  found  that  their  most  effective  service  will  be 
rendered  at  the  base,  under  the  supervision  of  non-commissioned 
officers  who  have  been  especially  trained  in  their  management. 

Syphilitic  Psychoses.  About  two  per  cent  of  the  mental  cases 
received  in  these  special  hospitals  have  general  paresis.  There 
is  convincing  evidence  that  the  stress  of  war  accelerates  the 
progress  of  this  disease.  As  older  men  enter  the  army  the  pro- 
portion of  paresis  rises.  In  the  navy,  which  has  been  largely 
augmented  by  the  enlistment  of  older  men  in  the  Naval  Reserve, 
general  paresis  has  attained  a  rate  quite  unknown  in  time  of 
peace.  Examinations  to  determine  the  prevalence  of  syphilis  in 
recruits  are  extremely  important  and  the  experience  of  the 
British  Army  and  Navy  shows  that  no  person  presenting  the 
slightest  suspicion  of  syphilis  of  the  central  nervous  system 
should  be  enlisted  or  commissioned  for  any  military  duty.  In 
view  of  the  social  distribution  of  this  disease  and  the  generally 
higher  age  of  officers,  paresis  is  to  be  borne  in  mind  especially  in 
the  examination  of  candidates  for  officers'  commissions. 

Manic-depressive  Insanity.  Patients  in  this  group  supply  about 
twenty  per  cent  of  all  admissions  to  military  hospitals  for  mental 
diseases.  The  great  proportion  of  those  with  depressed  phases 
is  very  striking.  Delusions  and  hallucinations  are  almost  inva- 
riably colored  by  military  experiences. 

Alcoholic  Psychoses.  Soldiers  with  delirium  tremens  are  ad- 
mitted to  special  hospitals  for  mental  diseases  if  they  are  stationed 
near  such  institutions.  This  disorder  is  now  confined  almost 
entirely  to  patients  on  leave  from  the  front.  During  the  early 
days  of  the  war  it  was  seen  most  frequently  among  those  who  had 
just  entered  military  service  and  found  their  supply  of  alcohol 
restricted.  The  delusional  types  of  alcoholic  psychoses  are  found 
in  older  men  stationed  at  bases  who  have  the  opportunity  to  con- 
tinue life-long  habits  of  drinking  to  excess.  Attempted  suicides 
are  very  common  among  alcoholics  seen  in  mihtary  service. 
Alcoholics  should  not  be  accepted  for  military  service  even  if  it  is 
possible  to  prevent  them  from  securing  alcohol  at  the  front.  Fur- 
loughs furnish  opportunities  for  drinking  and  the  time  and  effort 
spent  in  training  men  are  lost  through  attacks  on  such  occasions. 

Dementia  Praecox.     Patients  with  this  disorder  constitute  four- 


22  MENTAL  DISEASES  AND  WAR  NEUROSES 

teen  per  cent  of  those  admitted.  The  histories  of  these  cases  show 
that  in  most  instances  symptoms  were  manifested  shortly  after 
entering  the  military  service.  It  is  apparent  that  many  of  them 
had  been  psychotic  before  enlistment.  There  seems  to  be  no 
special  modification  of  symptoms  on  account  of  military  service. 

Epilepsy.  Seven  per  cent  of  cases  received  at  Dykebar  War 
Hospital  were  suffering  from  epilepsy.  With  one  exception  all 
had  had  the  disease  before  enlistment. 

Co7istitutional  Psychopathic  States.  A  very  large  number  of 
these  cases  are  received  in  the  special  military  hospitals  for  mental 
diseases.  They  probably  represent  but  a  small  proportion  of  such 
soldiers  in  the  army  for  the  percentage  is  large  in  the  various 
disciplinary  groups.  Unfortunately  the  nomenclature  used  in 
the  British  Army  did  not  permit  the  use  of  any  term  applicable 
to  these  cases  until  February,  1916,  when  the  War  OflRce  author- 
ized the  addition  of  "mental  instability"  to  the  list  of  mental 
diseases.  Many  cases  are  now  being  reported  under  this  heading. 
The  occasion  for  their  admission  is  usually  an  acute  psychotic 
episode  or  a  niedico-legal  situation. 

Outlook  in  Mental  Cases 
There  are  no  statistics  available  to  show  the  outcome  in  the 
mental  diseases  treated  in  military  hospitals.  Discharge  is  much 
more  likely  to  be  regulated  by  administrative  considerations  than 
by  clinical  ones.  Acute  conditions  seem  to  recover  very  quickly. 
Few  return  to  "first  line  duty."  The  statistics  indicate  a  much 
larger  proportion  than  is  actually  the  case.  The  number  of  those 
who  go  back  to  the  colors  is  made  up  for  the  most  part  of  patients 
who  have  recovered  from  delirium  tremens  and  those  with  war 
neuroses  who  have  been  incorrectly  admitted  to  institutions  for 
the  insane.  Infective-exhaustive  psychoses  are  much  more  likely 
to  be  regarded  as  "shell  shock"  than  as  mental  disorders.  The 
hospitals  for  mental  diseases  fail,  therefore,  to  get  these  very 
recoverable  cases  and  the  recovery  rate  in  such  institutions  suffers 
correspondingly . 

Summary 
Sorely  pressed  to  meet  the  tremendous  medical  problems  of  war, 
England  first  used  her  existing  civil  facilities  for  caring  for  mental 
diseases  among  soldiers.     Public  disapproval,  based  chiefly  upon 


MENTAL  DISEASES  28 

a  mistaken  attitude  toward  the  insane  and  toward  the  local  insti- 
tutions for  their  care,  forced  a  different  method  of  management. 
The  military  hospitals  for  the  insane,  created  without  exception 
by  converting  civil  institutions  for  mental  diseases,  failed  to  do 
much  more  than  provide  places  for  receiving  mental  cases  and 
giving  temporary  care.  The  clearing  hospital  is  in  size  and  per- 
sonnel woefully  inadequate  to  deal  with  the  important  issues 
which  should  be  determined  there  and  a  solution  to  the  problem 
presented  by  mental  diseases  among  soldiers  in  England  does  not 
seem  to  be  in  sight. 

For  the  United  States,  this  experience  carries  important  lessons. 
More  important  than  all  others  is  the  result  of  careless  recruit- 
ing. The  problem  of  dealing  with  mental  diseases  in  the  army — 
difficult  at  best — has  been  made  still  more  so  by  accepting  large 
numbers  of  recruits,  who  had  been  in  institutions  for  the  insane  or 
were  of  demonstrably  psychopathic  make-up.  The  next  most 
important  lesson  is  that  of  preparing,  in  advance  of  an  urgent  need, 
a  comprehensive  plan  for  establishing  special  mihtary  hospitals 
and  using  existing  civil  facilities  for  treating  mental  disease  in  a 
manner  that  will  serve  the  army  effectively  and  at  the  same  time 
safeguard  the  interests  of  the  soldiers,  of  the  government  and  of 
the  community. 


II.  WAR  NEUROSES   ("SHELL  SHOCK") 


n.  WAR  NEUROSES   ("SHELL  SHOCK") 

ALTHOUGH  an  excessive  incidence  of  mental  diseases  has 
been  noted  in  all  recent  wars,  it  is  only  in  the  present  one 
that  functional  nervous  diseases  have  constituted  a  major  medico- 
military  problem.  As  every  nation  and  race  engaged  is  suffering 
severely  from  these  disorders,  it  is  ajrgaxent  that  new  xsonditions 
of  warfare  are- chiefly  responsible  for  their  prevalence.  None  of 
these  new  conditions  is  more  terrible  than  the  sustained  shell  fire 
with  high  explosives  which  has  characterized  most  of  the  fighting. 
It  is  not  surprising,  therefore,  that  the  term  "shell  shock"  should 
have  come  into  general  use  to  designate  this  group  of  disorders. 
The  vivid,  terse  name  quickly  became  popular  and  now  it  is  ap- 
plied to  practically  any  nervous  symptoms  in  soldiers  exposed  to 
shell  fire  that  cannot  be  explained  by  some  obvious  physical  injury. 
It  is  used  so  very  looselj^  that  it  is  applied  not  only  to  all  func- 
tional nervous  diseases  but  to  well-known  forms  of  mental  disease, 
even  general  paresis.  Such  a  situation  is  most  unsatisfactory  and 
at  the  present  time  an  attempt  is  being  made  to  improve  the  no- 
menclature of  the  nervous  disorders  of  war. 

Discussion  of  clinical  features  of  the  war  neuroses  is  not  within 
the  scope  of  this  report,  which  deals  with  treatment  and  military 
management.*  It  is  impossible,  however,  even  to  define  the 
problem  with  which  we  are  dealing  without  a  few  general  observa- 
tions on  the  nature  of  the  disorders  which  are  grouped  under  the 
name  "shell  shock." 

The  subject  can  be  clarified  a  little  by  dividing  the  different 
conditions  so  designated  into  some  clinical  and  etiological  groups. 
First  should  be  considered  cases  in  which  the  patients  have  been 
actually  exposed  to  the  effects  of  high  explosives. 

1.  Not  infrequently,  just  how  often  it  is  impossible  to  say,  exploding  shells  or 
mines  cause  death  without  external  signs  of  injury.  Apparently  death  in  these 
cases  is  sometimes  due  to  damage  to  the  central  nervous  system. 

*These  extraordinarily  interesting  medical  problems  of  the  war  are  dealt  with  in  a  rapidly 
expanding  volume  of  special  literature.  The  July  number  of  Mental  Hygiene  (Vol.  I, 
No.  3)  contains  a  resume  of  this  literature.  One  hundred  and  forty-one  references  in 
English  are  given  in  Appendix  I  of  this  report.  Attention  is  directed  particularly  to  the 
contributions  of  Major  Frederick  M.  Mott  (71  and  72),  Prof.  G.  Elliot  Smith  (108), 
Capt.  Charles  S.  Meyers  (74),  Capt.  Clarence  B.  Farrar  (32),  Capt.  M.  D.  Eder  (28)  and 
to  the  extensive  report  by  Dr.  John  T.  MacCurdy  in  the  Psychiatric  Bulletin  (N.  Y.)  for 
July,  1917.     (The  numbers  refer  to  the  references  in  Appendix  I.) 

27 


28  MENTAL  DISEASES  AND   WAR  NEUROSES 

2.  In  another  group  of  cases  severe  neurological  symptoms  follow  burial  or 
concussion  by  explosions  in  characteristic  syndromes  suggesting  the  operation 
of  mechanical  factors.  The  studies  of  Major  Mott*indicate  that  concussion,  in 
aerial  compression  and  the  rapid  decompression  following  it,  "gassing"  from 
the  drift  gases  (carbon  monoxide  and  oxides  of  nitrogen)  generated  by  the  ex- 
plosion and  other  purely  mechanical  effects  of  shell  explosion  may  result  in 
transitory  or  permanent  neurological  symptoms  of  a  type  unfamiliar  in  the  neu- 
roses. 

There  can  be  no  question  of  the  propriety  of  supplying  the  term 
"shell  shock"  to  these  two  groups  of  cases  if  a  specific  term  is 
required. 

3.  Another  group  of  cases,  among  those  exposed  to  shell  fire,  includes  patients 
in  whom,  while  there  may  or  may  not  be  damage  to  the  central  nervous  system, 
the  symptoms  are  those  of  neuroses  familiar  in  civil  practice  even  though  colored 
in  a  very  distinctive  way  by  the  precipitating  cause.  In  this  group  of  cases,  in 
which  there  is  possibility  but  no  proof  of  damage  to  the  central  nervous  system, 
the  symptoms  present  which  might  be  attributable  to  such  damage  are  quite 
overshadowed  by  those  characteristic  of  the  neuroses. 

It  is  about  these  cases  that  much  controversy  exists.  Mott 
includes  them  in  his  group  of  "injuries  of  the  central  nervous 
system  without  visible  injury,"  holding  that  a  physical  or  a  chem- 
ical change  at  present  unknown  to  us  must  underlie  such  striking 
disabilities.  Others  give  less  weight  to  the  factor  of  physical 
damage  and  yet  recognize  its  existence  and  reconcile  the  wide 
range  of  neurotic  symptoms  with  the  very  minute  amount  of 
")  damage  which  may  exist  by  terming  these  cases  "traumatic 
neuroses."  Others  again  feel  that  psychogenetic  factors  deter- 
mine not  only  the  continuing  neurosis  but  even  the  initial  uncon- 
sciousness and  special  sense  disturbances. 

4.  There  is  a  group  of  cases  in  which  even  the  slightest  damage  to  the  central 
nervous  system  from  the  direct  effects  of  explosions  is  exceedingly  improbable, 
the  patients  being  exposed  only  to  conditions  to  which  hundreds  of  their  com- 
rades who  develop  no  sj'mptoms  are  exposed.  In  these  cases  the  symptoms, 
course  and  outcome  correspond  with  those  of  the  neuroses  in  civil  practice. 

If  all  neuroses  among  soldiers  were  included  in  these  groups  the 
use  of  the  term  "  shell  shock"  might  be  defended.  But  many  hun- 
dreds of  soldiers  who  have  not  been  exposed  to  battle  conditions 
at  all  develop  symptoms  almost  identical  with  those  in  men  whose 
nervous  disorders  are  attributed  to  shell  fire.  The  non-expedi- 
tionary forces  supply  a  considerable  proportion  of  these  cases. 

*Appendix  I,  reference  71. 


WAR  NEUROSES  29 

To  state  that,  in  the  cases  included  in  the  last  two  groups  of 
cases  in  which  shell  explosions  play  a  part,  the  mechanism  is  that  of 
a  neurosis  by  no  means  excludes  the  operation  of  physical  causes. 
Very  little  is  known,  however,  regarding  the  physiological  basis 
of  the  disorders  in  this  group  or  even  in  those  in  the  first  two 
groups  in  which  the  issues  are  apparently  predominantly  organic. 
It  may  be  that  in  the  latter  two  groups  endocrinitic  disturbances 
are  important.  Minute  injuries  of  the  cord  may  exist  and  factors 
such  as  exposure,  exhaustion,  vascular  disequilibrium  and  dis- 
orders of  metabolism  may  enter  into  their  causation.  Treatment 
directed  along  the  lines  suggested  by  such  an  etiology  has  thus  far 
proved  quite  ineffective,  however,  and  there  is  only  the  most 
slender  basis  of  experimental  work  to  show  that  such  factors  are 
important.  This  is  a  fertile  field  for  research.  It  is  earnestly 
hoped  by  all  those  consulted  in  England  that  the  United  States 
Army,  coniing  freshly  into  contact  with  this  problem,  will  or- 
ganize a  working  party  of  psychiatrists,  neurologists,  neuro-path- 
ologists  and  internists  and  try  to  clear  some  of  these  issues. 

It  is  the  opinion  of  most  psychiatrists  and  neurologists  who  have 
been  studying  and  treating  "shell  shock"  in  the  British  Army 
that  the  fourth  group  is  the  largest  and  most  important  and 
that,  whatever  the  unknown  physiological  basis,  psychological 
factors  are  too  obvious  and  too  important  in  these  cases  to  be 
ignored.  In  support  of  this  view  there  is  much  evidence,  some  of 
which  it  may  be  worth  while  to  give. 

1.  The  striking  excess  of  war  neuroses  among  officers.  The  ratio  of  officers  to 
men  at  the  front  is  approximately  1:30.  Among  the  wounded  it  is  1:24.* 
Among  the  patients  admitted  to  the  special  hospitals  for  war  neuroses  in  England 
during  the  year  ending  April  30, 1917,  it  was  1: 6. 

2.  The  rarity  of  war  neuroses  among  prisoners  exposed  to  mechanical  shock.f 

3.  The  rarity  of  war  neuroses  among  the  wounded  exposed  to  mechanical 
shock. 

4.  The  clinical  resemblance  which  the  war  neuroses  bear  to  the  neuroses  of 
civil  life  in  which  the  element  of  mechanical  shock  is  lacking  while  the  psycho- 
logical situations  are  somewhat  alike. 

5.  The  fact  that  severe  war  injuries  to  the  brain  and  spinal  cord  are  not  ac- 
companied by  symptoms  similar  to  those  in  "shell  shock,"  in  which  injuries  of 
less  degree  are  assumed. 

*Analysis  of  381,98."  casualties  between  August  4,  1914,  and  August  21,  1915,  reported 
in  a  statement  in  Parliament,  and  901,534  casualties  between  July,  1916,  and  July,  1917. 
jReferences  given  by  Capt.  C.  B.  Farrar  (Appendix  I,  reference  32). 


30  MENTAL  DISEASES  AND   WAR  NEUROSES 

6.  The  success  attending  therapeutic  measures  employed  with  reference  to 
the  psychological  situations  discovered  in  individual  cases. 

These  suggestive  facts  require  some  elaboration.  The  high 
prevalence  of  "shell  shock"  among  officers  corresponds  with  the 
distribution  of  the  neuroses,  with  reference  to  education  and  social 
grouping,  in  civil  life.  Soldiers  who  are  wounded  and  those  who 
are  taken  prisoners  in  battle  are  exposed  to  wind  concussion  and 
rapid  decompression  and  other  mechanical  factors  in  the  same 
degree  as  their  comrades  who  suffer  from  neuroses.  One  must 
conclude  from  the  fact  that  they  escape  that  being  wounded  or 
being  captured  provides  them  with  something  which  the  neurosis 
provides  for  others.  The  symptoms  exhibited  usually  bear  a  more 
direct  relation  to  the  existing  psychological  situation  than  they 
could  possibly  bear  to  the  localization  of  a  neurological  injury. 
Thus  a  soldier  who  bayonets  an  enemy  in  the  face  develops  an 
hysterical  tic  of  his  own  facial  muscles;  abdominal  contractures 
occur  in  men  who  have  bayonetted  enemies  in  the  abdomen ;  hys- 
terical blindness  follows  particularly  horrible  sights;  hysterical 
deafness  appears  in  those  who  find  the  cries  of  the  wounded  un- 
bearable and  men  detailed  to  burial  parties  develop  anosmia. 
KThe  psychological  basis  of  the  war  neuroses  (like  that  of  the 
neuroses  in  civil  life)  is  an  elaboration,  with  endless  variations,  of 
one  central  theme :  escape  from  anlntolerable  situation  in  real  life 
to  one  made  tolerable  by  the  neurosis.  The  conditions  which 
may  make  intolerable  the  situation  in  which  a  soldier  finds  him- 
self hardly  need  stating.  Not  only  fear,  which  exists  at  some  time 
in  nearly  all  soldiers  and  in  many  is  constantly  present,  but  horror, 
revulsion  against  the  ghastly  duties  which  must  be  sometimes  per- 
formed, intense  longing  for  home,  particularly  in  married  men, 
emotional  situations  resulting  from  the  interplay  of  personal 
conflicts  and  military  conditions,  all  play  their  part  in  making 
an  escape  of  some  sort  mandatory.  Death  provides  a  means 
which  cannot  be  sought  consciously.  Flight  or  desertion  is 
rendered  impossible  by  ideals  of  duty,  patriotism,  and  honor,  by 
the  reactions  acquired  by  training  or  imposed  by  discipline  and 
by  herd  reactions.  Malingering  is  a  military  crime  and  is  not  at 
the  disposal  of  those  governed  by  higher  ethical  conceptions. 
Nevertheless,  the  conflict  between  a  simple  and  direct  expression 
in  flight  of  the  instinct  of  self-preservation  and  such  factors  de- 


WAR  NEUROSES  31 

mands  some  sort  of  compromise.  Wounds  solve  the  problem 
most  happily  for  many  men  and  the  mild  exhilaration  so  often 
seen  among  the  wounded  has  a  sound  psychological  basis.  Others 
with  a  sufficient  adaptability  find  a  means  of  adjustment.  The 
neurosis  provides  a  means  of  escape  so  convenient  that  the  real 
source  of  wonder  is  not  that  it  should  play  such  an  important 
part  in  miUtary  life  but  that  so  many  men  should  find  a  satis- 
factory adjustment  without  its  intervention.  The  constitu- 
tionally neurotic,  having  most  readily  at  their  disposal  the 
mechanism  of  functional  nervous  diseases,  employ  it  most  fre- 
quently. They  constitute,  therefore,  a  large  proportion  of  all 
cases  but  a  very  striking  fact  in  the  present  war  is  the  number  of 
men  of  apparently  normal  mental  make-up  who  develop  war 
neuroses  in  the  face  of  the  unprecedentedly  terrible  conditions  to 
which  they  are  exposed. 

One  of  the  chief  objections  to  the  use  of  the  term  "shell  shock" 
Is  the  implication  it  conveys  of  a  cause  acting  instantly.  The 
train  of  causes  which  leads  to  the  neurosis  that  an  explosion  ushers 
in  is  often  long  and  complicated.  Apparently  in  many  mili- 
tary cases  mental  conflicts  in  the  personal  life  of  the  soldier 
that  are  not  directly  connected  with  military  situations  in- 
fluence the  onset  of  the  neuroses.  Thus  men  who  have  been 
doing  very  well  in  adapting  themselves  to  war  develop  "shell 
shock"  immediately  after  receiving  word  that  their  wives  have 
gone  away  with  other  men  during  their  absence. 

Approached  from  the  psychological  viewpoint,  the  symptoms 
in  the  war  neuroses  lose  much  of  their  weird  and  inexplicable  char- 
acter. Most  of  them  can  be  summed  up  in  the  statement  that 
the  soldier  loses  a  function  that  either  is  necessary  to  continued 
military  service  or  prevents  his  successful  adaptation  to  war.  The 
symptoms  are  found  in  widely  separated  fields.  Disturbances  of 
psychic  functions  include  delirium,  confusion,  amnesia,  hallucina- 
tions, terrifying  battle  dreams,  anxiety  states.  The  disturbances 
of  involuntary  functions  include  functional  heart  disorders,  low 
blood  pressure,  vomiting  and  diarrhea,  enuresis,  retention  or 
polyuria,  dyspnoea,  sweating.  Disturbances  of  voluntary  muscu- 
lar functions  include  paralyses,  tics,  tremors,  gait  disturbances, 
contractures  and  convulsive  movements.  Special  senses  may  be 
affected    producing   pains    and    anesthesias,    mutism,    deafness. 


32  MENTAL  DISEASES  AND  WAR  NEUROSES 

hyperacusis,  blindness  and  disorders  of  speech.  It  is  highly 
significant  that,  in  this  unprecedented  prevalence  of  functional 
nervous  diseases  among  soldiers,  no  symptoms  unfamiliar  to 
those  who  see  the  neuroses  in  civil  life  present  themselves. 

In  all  of  these  the  soldier  is  afflicted  with  more  or  less  incapacity 
without  obvious  explanation.  This  is  a  condition  involving  grave 
dangers.  His  condition  is  degrading  and  is  often  rendered  more 
so  by  the  punishment  or  ridicule  to  which  he  is  subjected.  For 
this  reason,  immediately  after  the  onset  of  the  symptoms  of 
the  neurosis,  the  patient  passes  through  a  very  critical  period. 
Improper  management  may  add  to  the  primary  neurological 
disability — which  is  largely  beyond  our  power  of  preventing — 
secondary  effects  which  go  even  further  in  producing  nervous  inva- 
lidism. Long-continued  treatment  in  general  hospitals,  confusion 
of  the  neurosis  present  with  the  organic  nervous  diseases,  and 
unintelligent  management,  all  tend  to  produce  the  chronic  "shell 
shock"  cases  which  are  so  famihar  in  the  special  hospitals  for 
these  disorders.  Symptoms  which  were  at  one  time  quite  easily 
removable  become  fixed  and  refractory  or  new  ones  are  con- 
stantly produced.  The  mental  attitude — the  patient's  morale  as 
a  soldier  and  his  attitude  toward  his  disorder — reaches  a  very  low 
level,  will  is  seriously  impaired  and  a  chronic  invalid  replaces  a 
temporarily  incapacitated  soldier.  These  are  matters  in  the  realm 
of  clinical  psychiatry  and  psycho-pathology  and  are  outside 
the  scope  of  this  report.  Space  is  given  to  them  here  only  be- 
cause of  their  very  important  bearing  upon  treatment  and  mili- 
tary management. 

Prevalence 

The  medical  statistics  of  the  war  are  as  yet  untabulated.  Even 
if  the  records  contained  the  information  desired  it  would  be  very 
difficult  to  state  the  prevalence  of  the  neuroses  on  account  of  the 
defective  nomenclature  employed.  It  is  doubtful  if  there  is 
another  group  of  diseases  in  which  more  confusion  in  terms  exists. 
Nervous  or  mental  symptoms  coming  to  attention  after  the 
soldier  has  been  exposed  to  severe  shell  fire,  are  almost  certain 
to  be  diagnosed  as  "shell  shock,"  and  yet  when  such  patients  are 
received  in  England,  well-defined  cases  of  general  paresis,  epilepsy 
or  dementia  praecox  are  often  found  among  them.  This  source 
of  confusion  tends  to  swell  the  number  of  cases  reported  under  the 


WAR  NEUROSES  S8 

term  "  shell  shock,"  but  there  are  many  other  sources  of  error  which 
tend  to  diminish  the  apparent  prevalence  of  the  war  neuroses. 
Chief  among  these  is  reporting  the  neuroses  under  the  name  of 
the  most  prominent  somatic  symptom.  The  largest  group  of 
cases  in  which  this  is  done  is  made  up  of  patients  diagnosed 
officially  as  having  disordered  action  of  the  heart  ("D.  A.  H."). 
Where  the  only  symptoms  are  cardio-vascular  ones  of  neurotic 
origin,  a  legitimate  question  of  medical  nomenclature  exists,  but 
one  sees  in  the  wards  or  hospitals  given  over  to  functional  heart 
disorders,  patients  with  hysterical  paralyses,  tics,  tremors,  mut- 
ism, anxiety  states  and  other  severe  neurotic  symptoms.  Another 
source  of  error  is  the  practice,  made  mandatory  by  a  recent  order, 
of  returning  these  cases  (when  occurring  in  soldiers  engaged  in 
actual  fighting)  as  "injuries  received  in  action." 

With  a  view  to  discovering  the  prevalence  of  the  neuroses  and 
insanity.  Sir  John  Collie,  President  of  the  Special  Pension  Board 
on  Neurasthenics,  made  an  analysis  of  170,000  discharge  certifi- 
cates for  disability,  interpreting  the  diagnoses  given  in  the  light 
of  his  very  large  experience.  He  found  that  the  neuroses  con- 
stituted 20  per  cent  of  these  discharges. 

The  number  of  cases  treated  in  the  special  hospitals  in  England 
gives  some  idea  of  the  prevalence  of  these  disorders,  but  the  fact 
that  the  number  of  troops  in  the  expeditionary  and  the  non- 
expeditionary  forces  is  confidential,  makes  it  impossible  to  give 
the  rates  for  the  two  great  divisions  of  the  British  Army.  During 
the  year  ending  April  30,  1916,  approximately  1,300  officers  and 
10,000  men  were  admitted  to  the  special  hospitals  for  "shell 
shock"  and  neurasthenics  in  Great  Britain.  The  1,800  beds  in 
these  special  hospitals  constitute  less  than  half  the  total  provisions 
in  Great  Britain  for  such  cases,  as  neurological  departments  exist 
in  the  large  territorial  general  hospitals  and  in  the  Royal  Victoria 
Hospital  in  Edinburgh.  Moreover,  a  constantly  increasing  num- 
ber of  these  cases  are  being  treated  in  France.  The  recoveries  in 
the  hospitals  there  diminish,  to  an  unknown  degree,  the  number  of 
cases  received  in  the  hospitals  in  Great  Britain.  It  is  the  belief 
of  those  who  have  made  an  effort  to  ascertain  the  prevalence  of 
the  war  neuroses,  that  the  rate  among  the  expeditionary  forces 
is  not  less  than  ten  per  thousand  annually,  and  among  the  home 
forces  not  less  than  three  per  thousand. 


34  MENTAL  DISEASES  AND  WAR  NEUROSES 

Treatment 

General  arrangements.  When  soldiers  suffering  from  func- 
tional nervous  disorders  began  to  arrive  in  England  from  the  ex- 
peditionary forces  in  September,  1914,  no  special  civil  or  military 
hospitals  existed  for  their  reception.  In  the  case  of  mental 
diseases  it  was  an  easy  task  to  convert  "D  Block"  at  the  Royal 
Victoria  Hospital  into  a  clearing  hospital  and  to  utilize  civil  in- 
stitutions for  the  insane  for  continued  care,  but  in  England,  as  in 
the  United  States,  there  are  no  public  civil  hospitals  that  are  en- 
gaged exclusively  in  the  work  of  treating  the  neuroses.  The 
special  civil  hospitals  for  organic  nervous  diseases  were  soon 
filled  with  patients  suffering  from  severe  neurological  injuries  and 
were  able  to  do  very  little  on  behalf  of  those  with  functional 
nervous  disorders. 

For  a  short  time  it  was  necessary  to  care  for  all  such  cases  in 
general  military  hospitals  for  medical  and  surgical  conditions. 
The  rapid  increase  in  the  number  of  such  cases  during  October  and 
November,  1914,  led  to  the  detail  of  a  special  medical  officer  to 
ascertain  their  special  needs  and  to  prepare  a  plan  for  meeting 
them.  The  recommendations  of  this  officer  that  special  institu- 
tions be  provided  for  functional  nervous  diseases  was  approved 
and  when,  in  December,  1914,  the  Moss  Side  State  Institution  at 
Maghull  was  turned  over  to  the  War  Office,  the  first  military 
hospital  for  functional  nervous  diseases  was  available.  This 
institution  was  particularly  suitable  for  this  purpose.  It  had 
been  completed  but  not  opened  for  the  care  of  mental  defectives 
of  the  delinquent  type  and  consisted  of  detached  villas  accom- 
modating 347  patients.*  The  number  of  these  patients  was  so 
great,  however,  that  general  hospitals  were  still  called  upon  to 
deal  with  them.  The  establishment  of  neurological  departments 
in  these  hospitals  partly  met  the  situation  until  additional  special 
hospitals  could  be  provided.  The  second  such  hospital  was 
secured  by  using  a  detached  portion  of  Middlesex  County  Asy- 
lum in  London.  This  hospital,  accommodating  278  additional 
patients,  was  renamed  the  Springfield  War  Hospital.*  The 
foresight  of  Sir  Alfred  Keogh  and  his  advisors  thus  enabled  Eng- 
land to  make  provision  for  these  cases  in  special  military  hospitals 
at  an  early  period  in  the  war. 

*Appendix  III. 


WAR  NEUROSES  35 

With  more  than  one  hospital  available,  it  was  possible  to  make 
different  provisions  for  different  classes  of  patients  suffering  from 
war  neuroses.     A  clearing  hospital  was  therefore  established  early 
in  1915  at  the  Foiu-th  London  Territorial  General  Hospital  where 
the  best  disposition  could  be  determined.     The  Maudsley  Hos- 
pital, a  psychopathic  hospital  for  the  County  of  London,*  was 
nearing  completion  at  this  time  and,  as  it  adjoined  the  Kings 
College  Hospital  which  formed  the  larger  part  of  the  Fourth 
London  Hospital,  it  was  utilized  as  a  nucleus  for  this  clearing 
station.     The  Maudsley  Hospital  accommodates  175  men  and 
20  officers;   the  neurological  section — "the  Maudsley  extension" 
— accommodates  450  men  and  80  officers.     Thus  by  the  spring 
of  1915,  England  was  provided  with  a  clearing  hospital  for  war 
neuroses  and  two  special  institutions  for  their  continued  care. 
Notwithstanding  this  provision,  by  far  the  greater  number  of 
cases  were  cared  for  in  general  hospitals  in  England  and  no 
special   provision   for   continued   treatment   existed   in   France. 
The  disadvantages  of  attempting  to  treat  functional  nervous  dis- 
orders in  general  hospitals  were  very  apparent  and  so  neurological 
sections  were  established  in  territorial  general  hospitals  in  Eng- 
land, Scotland  and  Wales  and  in  the  Royal  Victoria  Hospital  at 
Netley.     Other  special  hospitals  have  been  provided   since,   a 
directory  and  descriptions  of  those  visited  being  given  in  Appendix 

m.t 

When  the  submarines  commenced  to  sink  hospital  ships  indis- 
criminately last  year  a  great  deal  of  the  medical  work  previously 
done  in  England  was  undertaken  in  France  and  so  special  provi- 
sions for  functional  nervous  cases  were  made  at  Havre,  Ireport, 
Boulogne,  Rouen  and  Etaples.  Formerly  little  more  than  estab- 
lishing the  diagnosis  was  done  in  France.  It  is  likely  that  the 
work  of  caring  for  these  cases  will  be  turned  over  more  and  more 
to  the  special  hospitals  in  France  as  the  results  of  treatment  there 
have  been,  on  the  whole,  so  much  more  successful  than  in  home 
territory. 

A  recent  extension  of  treatment  is  that  of  providing  care  still 

*Appendix  III. 

fAn  interesting  account  of  the  arrangements  for  the  care  of  soldiers  with  war  neuroses 
is  given  in  a  special  article  by  Lt.  Col.  William  Aldren  Turner.  (Appendix  I,  refer- 
ence 125.) 


36  MENTAL  DISEASES  AND   WAR  NEUROSES 

nearer  the  front.  The  striking  results  obtained  in  Casualty  Clear- 
ing Stations  and  similar  advanced  posts  in  the  French  Sanitary 
Service  (pastes  de  chirurgie  d'urgence)  are  confirmed  by  many 
observers. 

Capt.  William  Brown,  a  psycliiatrist,  who  has  recently  had  the  opportunity  of 
working  in  a  Casualty  Clearing  Station  of  the  British  Expeditionary  Forces 
reports  that  of  200  nervous  and  mental  cases  which  passed  through  his  hands  in 
December,  1916,  34  per  cent  were  evacuated  to  the  base  after  seven  days'  treat- 
ment and  66  per  cent  returned  to  duty  on  the  firing  line  after  the  same  average 
period  of  treatment.  Four  of  these  cases  reappeared  at  the  same  Casualty 
Clearing  Station. 

Capt.  Louis  Casamajor  of  the  U.  S.  Army,  neurologist  to  Base  Hospital  No.  1, 
British  Expeditionary  Force,  says  in  a  recent  letter:  "It  is  a  mistake  to  send 
these  cases  to  England.  We  need  an  intermediate  step  between  the  general 
hospital  and  the  convalescent  camp.  Of  course  they  never  should  get  into 
general  hospitals  at  all  but  should  be  sent  from  Casualty  Clearing  Stations  direct 
to  neuro-psychiatric  hospitals.  ...  I  hope  our  army  will  have  a  psychia- 
trist in  each  Casualty  Clearing  Station  to  weed  these  cases  out  and  send  them 
to  their  proper  places  and  not  have  them  knock  around  from  one  general  hospital 
to  another,  being  pampered  into  hard-set  neuroses."' 

Leri,  working  in  the  neuro-psychiatric  center  of  the  second  French  Army, 
reports  that  91  per  cent  of  the  cases  received  from  July  to  October,  1916,  were 
returned  to  the  fighting  line.  Marie  reports  that  the  neuroses  are  less  frequently 
met  with  in  Paris  now  that  they  are  treated  immediately  upon  their  appearance 
in  the  Army  neuro-psychiatric  centers.* 

Major  Frederick  W.  Mott  says:  "I  regard  tliis  matter  of  preventing  the  fixa- 
tion of  a  functional  paralysis  as  of  supreme  importance  both  in  respect  to  the 
welfare  of  the  individual  and  from  the  economic  point  of  view  of  the  state." 

Roussy  and  Boisseau.f  describing  the  work  of  an  army  neuro-psychiatric 
center  say :  "  The  results  obtained  after  six  months  show  that  a  neuro-psychiatric 
center  can  render  incontestable  services  to  an  army  both  from  a  medical  and  a 
military  point  of  view.  For  functional  nervous  cases  it  avoids  sojourns  (more 
dangerous  the  more  they  are  prolonged)  in  the  hospitals  at  the  rear  where  these 
patients  are  generally  lost.  It  allows  of  the  treatment  of  other  nervous  or  mental 
cases  that  are  quickly  curable  and  the  direct  evacuation  to  the  special  centers 
in  the  interior  of  those  more  seriously  affected." 

Captain  C.  B.  FarrarJ  says:  "Moreover  it  seems  to  be  a  fact  that  treatment 
is  more  satisfactorily  carried  out  and  cures  more  speedily  accomplished  in  hospi- 
tals close  to  the  front  and  where  the  spirit  of  army  discipline  is  most  felt.  It  is 
conceded  that  the  worst  possible  place  to  treat  a  case  of  war  neurosis  is  in  his 
home  town,  where  in  so  far  especially  as  the  more  striking  objective  symptoms 
are  concerned,  the  sympathetic  wonderment  and  commiseration  of  friends  create 

*Remte  neurologique  (Nov.-Dec,  1916). 

\Pari3  mldicale,  1:14-20  (.Ian.  1,  1916). 

XAmerican  journal  of  insanity,  73:  711-712  (April,  1917). 


WAR  NEUROSES  37 

a  positive  demand  which  the  ideogenic  factor  of  the  patient's  illness  continues 
faithfully  to  supply.  In  hospitals  close  behind  the  lines  there  is  still  the  atmos- 
phere of  the  front  and  a  mental  tone  which  comes  from  mass-suggestion  of  men 
striving  shoulder  to  shoulder.  This  mental  tone  is  eminently  supportive  and 
therapeutic,  but  with  the  transfer  of  patients  to  interior  hospitals  far  behind  the 
lines  it  naturally  gives  way.  The  circumstances  which  produce  it  are  no  longer 
operative  and  the  nervous  relaxation  and  reaction  which  ensue  are  often  con- 
spicuously and  painfully  evident.  Out  of  danger,  far  from  the  front,  perhaps 
among  hero-worshipping  friends,  the  invalid  is  unavoidably  conscious  of  himself 
more  as  an  individual  and  less  as  a  link  in  the  battle  Ime.  All  the  conditions  are 
favorable  for  the  fixation  and  reinforcement  of  the  neurosis  as  an  ideogenic 
process.  Too  often  he  is  found  to  be  the  victim  not  only  of  his  malady,  but  of  his 
friends  as  well,  and  in  more  senses  than  one." 

General  principles.  Methods  of  treatment  employed  in  differ- 
ent special  hospitals  are  described  in  Appendix  III.  With  so 
much  regarding  the  war  neuroses  the  subject  of  controversy,  it  is 
not  surprising  that  different  methods  of  treatment  have  come  into 
existence.  The  Royal  Army  Medical  Corps  has  seen  fit  to  leave 
these  matters  largely  to  the  specialists  in  charge  of  the  different 
hospitals  and  so  the  treatment  in  each  reflects,  to  a  certain  degree, 
the  conception  of  the  nature  of  war  neuroses  held  by  the  medical 
officer  in  charge.  Certain  general  principles  regarding  treatment 
may  be  stated. 

The  experience  of  the  British  "shell  shock"  hospitals  empha- 
sizes the  fact  that  the  treatment  of  the  war  neuroses  is  essentially 
a  problem  in  psychological  medicine.  While  patients  with  severe 
symptoms  of  long  duration  recover  in  the  hands  of  physicians 
who  see  but  dimly  the  mechanism  of  their  disease  and  are  unaware 
of  the  means  by  which  recovery  actually  takes  place,  no  credit 
belongs  to  the  physician  in  such  cases  and  but  little  to  the  type 
of  environment  provided.  In  the  great  majority  of  instances  the 
completeness,  promptness  and  durability  of  recovery  depend 
upon  the  insight  shown  by  the  medical  officers  under  whose  charge 
the  soldiers  come  and  their  resourcefulness  and  skill  in  applying 
treatment. 

The  first  step  in  treatment  is  a  careful  study  of  the  individual 
case.  There  are  no  specific  formulae  for  the  cure  of  mutism, 
paralyses  or  tremors  or  other  manifestations  of  war  neuroses. 
These  are  symptoms  and  the  patient  must  be  treated  as  well  as 
his  symptoms.  As  in  all  other  psychiatric  work,  efforts  must 
first  be  made  to  gain  an  understanding  of  the  personality — the 


38  MENTAL  DISEASES  AND  WAR  NEUROSES 

fabric  of  the  individual  in  whom  the  neurosis  has  developed. 
His  resources  and  limitations  in  mental  adaptation  will  deter- 
mine in  a  large  measure,  the  specific  line  of  management.  The 
military  situation  is  most  striking  but  the  problem  which  life 
in  general  presents  to  the  individual  and  the  type  of  adaptation 
which  he  has  found  serviceable  in  other  emergencies  are  of  as 
much  importance  as  the  specific  causes  for  failure  in  the  existing 
situation.  The  disorder  must  be  looked  at  as  a  whole.  The 
incident  which  seems  to  have  precipitated  the  neurosis — whether 
shell  explosion,  burial  or  disciplinary  crisis — must  receive  close 
attention  but  not  to  the  exclusion  of  other  factors  less  dramatic 
but  often  more  potent  in  the  production  of  the  neurosis.  It  has 
often  been  said  that  some  of  the  symptoms  of  hysteria  are  the 
work  of  the  physician  and  are  created — not  disclosed — by  neu- 
rological examinations.  This  is  apparently  true,  but  the  question 
whether  analgesia  can  exist  until  the  pin  prick  demonstrates  it  is 
somewhat  like  the  question  whether  sound  can  exist  without  an 
ear  to  receive  it.  It  is  not  only  true,  but  a  fact  of  great  practical 
importance,  that  a  skilful,  searching,  psychological  examination 
often  constitutes  the  first  step  in  actual  treatment. 

In  the  analysis  of  the  situation,  as  well  as  in  the  subsequent 
management  of  the  patient,  the  medical  officer's  attitude  is  of 
much  importance.  He  must  be  immune  to  surprise  or  chagrin. 
Although  understanding  sympathy  is  nearly  as  useful  as  misdi- 
rected sympathy  is  harmful,  he  must  always  remain  in  firm  con- 
trol.  . 

^  ^^=^^^The  resources  at  the  disposal  of  the  physician  in  treating  the 
war  neuroses  are  varied.  The  patient  must  be  re-educated  in 
will,  thought,  feeling  and  function.  Persuasion,  a  powerful  re- 
source, may  be  employed,  directly  backed  by  knowledge  on  the 
part  of  the  patient  as  well  as  the  physician  of  the  mechanism  of 
the  particular  disorder  present.  Indirectly,  it  must  pervade  the 
atmosphere  of  the  special  ward  or  hospital  for  "shell  shock." 
Hypnotism  is  valuable  as  an  adjunct  to  persuasion  and  as  a 
means  of  convincing  the  patient  that  no  organic  disease  or 
injury  is  responsible  for  his  loss  of  function.  Thus  in  mutism 
the  patient  speaks  under  hypnosis  or  through  hypnotic  suggestion 
and  thereafter  must  admit  the  integrity  of  his  organs  of  speech. 
The  striking  results  of  hypnotism  in  the  removal  of  symptoms 


WAR  NEUROSES  39 

are  somewhat  offset  by  the  fact  that  the  most  suggestible  who 
yield  to  it  most  readily  are  particularly  likely  to  be  the  constitu- 
tionally neurotic.  A  mental  mechanism  similar  to  that  which  pro- 
duced the  disorder  is  being  used  in  such  cases  to  bring  about  a  cure. 

Recovery  within  the  sound  of  artillery  or  at  least  "somewhere 
in  France"  is  more  prompt  and  durable  than  that  which  takes 
place  in  England.  For  severe  cases  and  those  which  through  mis- 
management have  developed  the  unfortunate  secondary  symp- 
toms of  "shell  shock"  and  in  whom  long-continued  treatment  is 
nectary,  a  rural  place  is  best. 

^^e-education  by  physical  means  is  a  valuable  adjunct  to  treat- 
ment in  recent  cases  but  particularly  in  chronic  cases  who  have 
been  mismanaged  and  in  those  who  are  recovering  from  long  con- 
tinued paralyses,  tics,  mutism  and  gait  disorders.  While  drills 
and  physical  exercises  have  their  specific  uses,  occupation  is  the 
best  means.     Non-productive  occupations  should  be  avoided. 

Occupations  are  conveniently  classified  as : 

1.  Bed. 

2.  Indoor. 

3.  Outdoor. 

1.  Basket-making  and  net-making  are  good  bed  occupations 
for  cases  with  extensive  paralyses,  as  are  making  surgical  dress- 
ings and  various  minor  finishing  operations  (sandpapering,  polish- 
ing, etc.)  on  products  of  the  shops.  All  occupations,  and  es- 
pecially those  which  are  carried  on  by  patients  seriously  incapaci- 
tated, should  be  regarded  as  only  steps  in  a  process  of  progressive 
education.  Every  effort  must  be  made  to  prevent  skill  acquired  in 
them  from  being  considered  as  a  substitute  for  full  functional 
activity.  Herein  is  an  important  difference  between  the  "re- 
education" of  neurotic  and  orthopedic  cases.  In  the  latter  the 
purpose  is  often  to  make  the  remaining  sound  limb  take  on  the 
functions  of  one  which  is  missing  or  permanently  disabled.  The 
function  held  in  abeyance  through  neurotic  symptovis  must  never  be 
looked  upon  as  lost.  It  can  and  must  be  restored  and  Lf  another 
function  is  developed  as  its  surrogate  the  day  of  full  recovery  is 
thereby  postponed.  Bed  occupations,  therefore,  must  always  be 
regarded  as  the  first  steps  in  a  series  which  is  to  culminate  in  full 
activity.  Progress  through  achievements  constantly  more  diffi- 
cult is  the  keynote  of  re-education  in  the  war  neuroses. 


40  MENTAL  DISEASES  AND   WAR  NEUROSES 

2.  A  wide  variety  of  indoor  occupations  should  be  provided  in- 
cluding at  the  minimum  carpentry,  wood  carving,  metal  work  and 
cement  work.  Printing,  bookbinding,  cigarette  making,  electric 
wiring  and  other  work  should  be  added  as  opportunities  permit. 

3.  Farming,  gardening  and  building  operations  are  desirable 
outdoor  occupations.  Where  possible,  wood  sawing  and  chopping 
are  very  desirable  as  is  the  care  of  stock  not  requiring  much  land 
(squabs,  guinea  pigs,  rabbits,  game,  frogs). 

Before  even  the  simplest  occupation  can  be  engaged  in  it  is 
sometimes  necessary  to  re-educate  paraplegics  and  ataxics  in 
walking  and  co-ordination.  Just  as  soon  as  possible,  exercises 
should  be  replaced  by  productive  occupations  which  will  accom- 
plish the  same  results  more  quickly  and  more  satisfactorily.  The 
same  is  true  of  gymnastic  exercises  which  in  the  early  steps  of 
treatment  constitute  a  valuable  resource  but  which  should  be 
replaced  by  specially  devised,  useful  tasks.  Swimming  has  a 
unique  place  in  the  treatment  of  gait  disturbances,  paralyses  and 
tics.  One  of  the  first  pieces  of  construction  undertaken  by  the 
outdoor  patients  at  a  reconstruction  center  should  be  that  of 
building  a  large  concrete  swimming  tank. 

Hydrotherapy  and  electrotherapy  have  a  distinct  value  when 
they  are  applied  with  absolute  sincerity  and  full  realization  on 
the  part  of  patient  and  medical  officer  of  the  role  which  they 
actually  play  in  the  treatment  of  functional  nervous  diseases. 

The  experience  in  English  hospitals  has  demonstrated  the  great 
danger  of  aimless  lounging,  too  many  entertainments  and  relax- 
ing recreations  such  as  frequent  motor  rides,  etc.  It  must  be 
remembered  that "  shell  shock"  cases  suffer  from  a  disorder  of  will 
as  well  as  function  and  it  is  impossible  to  effect  a  cure  if  attention 
is  directed  to  one  at  the  expense  of  the  other.  As  Dr.  H.  Crichton 
Miller  has  put  it,  "  'shell  shock'  produces  a  condition  which  is 
essentially  childish  and  infantile  in  its  nature.  Rest  in  bed  and 
simple  encoiu-agement  is  not  enough  to  educate  a  child.  Progress- 
ive daily  achievement  is  the  only  way  whereby  manhood  and 
self-respect  can  be  regained." 

Outcome 
It  was  impossible  for  me  to  discover  the  end-results  of  treat- 
ment.    The  following  table  shows  the  disposal  of  731  discharges 


WAR  NEUROSES  41 

from  the  Red  Cross  Military  Hospital  at  Maghull  during  the  year 

ending  June  30,  1917. 

Number  Per  cent 

To  military  duty 153  20.9 

Tocivillife 476  65.1 

To  other  hospitals 88  12.0 

To  civil  institutions  for  the  insane 7  1.0 

Died 3  0.4 

Deserted 4  0.6 

731  100.0 

It  is  the  opinion  of  the  commanding  officer  of  this  hospital  that 
few  men  (with  the  severe  or  chronic  types  of  neuroses  there  re- 
ceived) can  be  sent  back  to  military  duty  at  the  front.  More 
could  be  returned  to  duty  at  the  base  but  for  the  fact  that  after 
having  been  in  a  "shell  shock  hospital,"  they  are  regarded  as 
being  poor  material  and  little  effort  is  taken  to  train  them  for  their 
new  duties.  Under  such  conditions  the  men  become  discouraged 
and  soon  show  signs  of  relapse.  Those  discharged  to  civil  life 
have  done  satisfactorily — as  might  be  expected  when  one  bears  in 
mind  the  genesis  of  the  neuroses  in  war. 

At  the  Granville  Canadian  Special  Hospital  at  Ramsgate, 
upwards  of  60  per  cent  of  the  patients  admitted  were  returned  to 
the  front.  The  experience  of  this  hospital  is  of  special  value  to  us 
because  the  cases  treated  are  those  which  seem  likely  to  recover 
within  six  months.  All  others  and  those  who  do  not  improve 
quickly  at  Ramsgate  are  sent  to  Canada.  It  would  be  wise  for 
the  United  States  Army  to  adopt  a  similar  policy. 

In  the  special  wards  established  in  France  the  recoveries  are 
still  more  numerous.* 

It  is  evident  that  the  outcome  in  the  war  neuroses  is  good  from 
a  medical  point  of  view  and  poor  from  a  military  point  of  view. 
It  is  the  opinion  of  all  those  consulted  that,  with  the  end  of  the 
war,  most  cases,  even  the  most  severe,  will  speedily  recover,  those 
who  do  not  being  the  constitutionally  neurotic  and  patients  who 
have  been  so  badly  managed  that  very  unfavorable  habit-reac- 
tions have  developed.  This  cheering  fact  brings  little  consolation, 
however,  to  those  who  are  chiefly  concerned  with  the  wastage  of 

*Pp.  36-37. 


42  MENTAL  DISEASES  AND  WAR  NEUROSES 

fighting  men.  The  lesson  to  be  learned  from  the  British  results 
seems  clear — that  treatment  by  medical  officers  with  special 
training  in  psychiatry  should  be  made  available  just  as  near  the 
front  as  military  exigency  will  permit  and  that  patients  who  can- 
not be  reached  at  this  point  should  be  treated  in  special  hospitals 
in  France  until  it  is  apparent  that  they  cannot  be  returned  to  the 
firing  lines.  As  soon  as  this  fact  is  established  military  needs  and 
humanitarian  ends  coincide.  Patients  should  then  be  sent  home 
as  soon  as  possible.  The  military  commander  may  have  the  satis- 
faction of  knowing  that  food  need  not  be  brought  across  to  feed 
a  soldier  who  can  render  no  useful  military  service,  and  the 
medical  officer  may  feel  that  his  patient  will  have  what  he  most 
needs  for  his  recovery — home  and  safety  and  an  environment  in 
which  he  can  readjust. 

Looking  at  the  matter  from  a  military  point  of  view  alone,  one 
might  ask  whether  it  is  not  desirable  to  send  home  all  "shell 
shock"  cases — in  whom  so  much  effort  residts  in  so  few  recoveries. 
Such  a  decision  would  be  as  unfortunate  from  a  military  as  from 
a  humanitarian  standpoint.  Its  immediate  effect  would  be  to 
increase  enormously  the  prevalence  of  the  war  neuroses.  In  the 
unending  conflict  between  duty,  honor  and  discipline,  on  the  one 
hand,  and  homesickness,  horror,  and  the  urgings  of  the  instinct 
of  self-preservation  on  the  other,  the  neurosis — as  a  way  out — is 
already  accessible  enough  in  most  men  without  calling  attention 
to  it  and  enhancing  its  value  by  the  adoption  of  such  an  admin- 
istrative policy. 

Medico-legal  Relations 
The  sudden  appearance  of  marked  incapacity,  without  signs  of 
injury,  in  a  group  of  men  to  whom  invalidism  means  a  sudden 
transition  from  extreme  danger  and  hardship  to  safety  and  com- 
fort, quite  naturally  gives  rise  to  the  suspicion  of  malingering. 
The  general  knowledge  among  troops  of  the  more  common  symp- 
toms of  "shell  shock"  and  of  the  fact  that  thousands  of  their 
comrades  suffering  from  it  have  been  discharged  from  the  army 
suggests  its  simulation  to  men  who  are  planning  an  easy  exit  from 
military  service  by  feigning  disease.  It  is  therefore  of  much 
military  importance  that  medical  officers  be  not  deceived  by  such 
frauds.  On  the  other  hand,  especially  before  the  clinical  charac- 
ters and  remarkable  prevalence  of  war  neuroses  among  soldiers 


WAR  NEUROSES  4S 

had  become  familiar  facts,  not  a  few  soldiers  suffering  from 
these  disorders  were  executed  by  firing  squads  as  malingerers. 
Instances  are  also  known  where  hysterics  have  committed  suicide 
after  having  been  falsely  accused  of  malingering.  Mistakes  of 
this  kind  are  especially  likely  to  occur  when  the  patients  have  not 
been  actually  exposed  to  shell  fire  on  account  of  the  idea  so  firmly 
fixed  in  the  minds  of  most  line  officers  and  some  medical  men  that 
the  war  neuroses  are  always  due  to  mechanical  shock. 

The  diagnosis  between  neuroses  and  malingering  may  some- 
times be  extremely  difficult  but  usually  it  is  easy  when  the  exam- 
iner is  familiar  with  both  conditions.  The  difficulties  arise  from 
the  fact  that  in  both,  a  disease  or  a  symptom  is  simulated.  As 
Bonnal  says,  "The  hysteric  is  a  malingerer  who  does  not  lie." 
The  cardinal  point  of  difference  is  that  the  malingerer  simulates  a 
disease  or  a  symptom  which  he  has  not  in  order  to  deceive  others. 
He  does  this  consciously  to  attain,  through  fraud,  a  specific  selfish 
end — usually  safety  in  a  hospital  or  discharge  from  the  military 
service.  He  lies  and  knows  that  he  lies.  The  hysteric  deceives 
himself  by  a  mechanism  of  which  he  is  unaware  and  which  is  beyond 
his  power  consciously  to  control.  He  is  usually  not  aware  of  the 
precise  purpose  which  his  illness  serves.  This  is  shown  by  the 
fact  that,  in  many  cases,  all  that  is  necessary  for  recovery  is  to 
demonstrate  clearly  to  the  patient  the  mechanism  by  which  this 
disability  occurred  and  the  unworthy  end  to  which,  unconsciously, 
it  was  directed. 

There  are  a  number  of  distinctive  points  of  difference  between 
hysteria  and  malingering,  two  of  which  it  may  be  interesting  to 
mention. 

The  malingerer,  conscious  of  his  fraudulent  intent  and  fearful 
of  its  detection,  dreads  examinations.  The  hysteric  invites 
examinations,  as  is  well  known  to  physicians  in  civil  practice. 
When  he  has  the  opportunity  he  makes  the  rounds  of  clinics  and 
physicians,  especially  delighting  in  examinations  by  noted  spe- 
cialists. 

The  hysteric,  in  addition  to  the  symptoms  of  which  he  com- 
plains, often  presents  objective  symptoms  of  which  he  is  unaware. 
The  malingerer,  unless  of  low  intelligence,  confines  his  complaints 
to  the  disease  or  symptom  which  he  has  decided  to  simulate. 

Malingering  may  follow  or  prolong  a  neurosis.     This  is  not 


44  MENTAL  DISEASES  AND  WAR  NEUROSES 

infrequently  the  case  when  mutism  is  succeeded  by  aphonia.  In 
such  cases  the  clinical  picture  presents  changes  very  apparent  to 
the  experienced  psychiatrist  but  it  must  be  remembered  that 
malingerers  (like  criminals  in  civil  Ufe)  are  often  very  neuro- 
pathic individuals. 

The  gravity  of  malingering  as  a  military  offense  In  an  army  in 
the  field  justifies  the  recommendation  that  no  case  in  which  the 
possibility  of  a  neurosis  or  psychosis  exists  shall  be  finally  dealt 
with  until  the  subject  is  examined  by  a  neurologist  or  psychia- 
trist. If  neuro-psychiatric  wards  are  provided  in  base  hospitals 
in  France  as  well  as  in  the  United  States,  such  an  examination 
will  be  feasible  in  practically  all  cases  without  causing  undue  delay. 
The  knowledge  that  malingerers  are  subjected  to  expert  examina- 
tions always  tends  to  discourage  soldiers  from  this  practice. 


m.    RECOMMENDATIONS  FOR  THE  UNITED  STATES 

ARMY 


in.    RECOMMENDATIONS  FOR  THE  UNITED  STATES  ARMY 

rr^HE  following  recommendations  for  the  treatment  of  mental 
A  diseases  and  war  neuroses  ("shell  shock")  in  the  United 
States  troops  are  based  chiefly  upon  the  experience  of  the  British 
Army  in  dealing  with  these  disorders,  as  outUned  in  the  foregoing 
report.  The  advice  of  British  medical  officers  engaged  in  this 
special  work  has  aided  greatly  in  formulating  the  plans  presented. 
At  the  same  time  conditions  imposed  by  the  necessity  of  conduct- 
ing our  military  operations  three  thousand  miles  away  from  home 
territory  have  been  borne  in  mind. 

It  seems  desirable  to  consider  separately  in  these  recommenda- 
tions, expeditionary  and  non-expeditionary  forces.  It  is  neces- 
sary to  deal  separately  with  mental  and  nervous  diseases  in  the 
United  States  but  not  in  France.  While  facilities  existing  at  home 
can  be  utilized  for  the  treatment  of  mental  diseases  it  is  necessary 
to  create  new  ones  for  the  treatment  of  the  war  neuroses.  In 
France,  where  all  facilities  for  treatment  must  be  created  by  the 
medical  department,  the  distinction  between  psychoses  and 
neuroses  need  not  be  drawn  so  closely.  Consequently,  simpler 
and  more  effective  methods  of  administrative  management  can  be 
devised. 

The  importance  of  providing,  in  advance  of  their  urgent  need, 
adequate  facilities  for  the  treatment  and  management  of  nervous 
and  mental  disorders  can  hardly  be  overstated.  The  European 
countries  at  war  had  made  practically  no  such  preparations  and 
they  fell  into  difficulties  from  which  they  are  now  only  commenc- 
ing to  extricate  themselves.  We  can  profit  by  their  experience 
and,  if  we  choose,  have  at  our  disposal,  before  we  begin  to  sustain 
these  types  of  casualties  in  very  large  numbers,  a  personnel  of 
specially-trained  medical  officers,  nurses  and  civilian  assistants 
and  an  efficient  mechanism  for  treating  mental  and  nervous  dis- 
orders in  France,  evacuating  them  to  home  territory  and  continu- 
ing their  treatment,  when  necessary,  in  the  United  States. 

Although  it  might  be  considered  more  appropriately  under  the 
heading  of  prevention  than  under  that  of  treatment,  the  most 
important  recommendation  to  be  made  is  that  of  rigidly  excluding 
insane,  feebleminded,  psychopathic  and  neuropathic  individuals 

47 


48  MENTAL  DISEASES  AND  WAR  NEUROSES 

from  the  forces  which  are  to  be  sent  to  France  and  exposed  to  the 
terrific  stress  of  modern  war.  Not  only  the  medical  officers  but 
the  line  officers  interviewed  in  England  emphasized,  over  and  over 
again,  the  importance  of  not  accepting  mentally  unstable  re- 
cruits for  miUtary  service  at  the  front.  If  the  period  of  training 
at  the  concentration  camps  is  used  for  observation  and  examina- 
tion, it  is  within  our  power  to  reduce  very  materially  the  difficult 
problem  of  caring  for  mental  and  nervous  cases  in  France,  in- 
crease the  military  eflSciency  of  the  expeditionary  forces  and  save 
the  country  millions  of  dollars  in  pensions.  Sir  William  Osier, 
who  has  had  a  large  experience  in  the  selection  of  recruits  for  the 
British  Army  and  has  seen  the  disastrous  results  of  carelessness 
in  this  respect,  feels  so  strongly  on  the  subject  that  he  has  recently 
made  his  views  known  in  a  letter  to  the  Journal  of  the  American 
Medical  Association*  in  which  he  mentions  neuropathic  make-up 
as  one  of  the  three  great  causes  for  the  invariable  rejection  of  re- 
cruits. In  personal  conversation  he  gave  numerous  illustrations 
of  the  burden  which  the  acceptance  of  neurotic  recruits  had  un- 
necessarily thrown  upon  an  army  struggling  to  surmount  the 
difficult  medical  problems  inseparable  from  the  war. 

It  is  most  convenient  to  summarize  the  recommendations  as 
follows  and  then  to  discuss  each  one  somewhat  in  detail: 

SUMMARY  OF  RECOMMENDATIONS  FOR  THE  CARE  AND   TREATMENT 
OP  MENTAL  DISEASES  AND  WAR  NEUROSES   ("  SHELL  SHOCK ") 

IN   THE   EXPEDITIONARY    FORCES 
Overseas 

1.  Base  Section  of  Lines  of  Communication 

(a)  A  Special  Base  Hospital  of  500  beds  for  neuro-psychiatric  cases,  located  at  the 
base  upon  which  each  army  (of  500,000-600,000)  rests.  These  special  base 
hospitals  to  be  used  for  cases  hkely  to  recover  and  return  to  active  duty  within 
six  months.  Other  cases  to  be  cared  for  while  waiting  to  be  evacuated  to  the 
United  States. 

(b)  One  or  more  Special  Convalescent  Camps  in  connection  with  (and  conducted  as 
part  of)  each  Special  Base  Hospital. 

2.  Advanced  Section  of  Lines  of  Communication 

(a)  Special  Neuro-Psychiatric  Wards  of  30  beds  in  charge  of  three  psychiatrists  and 
neurologists  for  each  base  hospital  having  an  active  ser\ice.  These  wards  to  be 
used  for  observation  (including  medico-legal  cases)  and  for  emergency  treat- 
ment of  mental  and  nervous  cases. 

(b)  Detail  of  a  psychiatrist  or  neurologist  attached  to  the  neuro-psychiatric  wards 
of  base  hospitals,  to  evacuation  hospitals  or  stations  further  advanced  as  op- 
portunities permit. 

'Journal  American  medical  association.  Vol.  LXIX,  No.  4,  p.  290  (July  28,  1917). 


RECOMMENDATIONS  FOR  UNITED  STATES  ARMY    49 

United  States 

1.  Mental  Diseases  (insane) 

(a)  One  or  more  Clearing  Hospitals  for  reception,  emergency  treatment,  classifi- 
cation and  disposition  of  mental  cases  among  enlisted  men  invalided  home. 

(b)  Clearing  Wards  (in  connection  with  general  hospitals  for  officers  or  private  in- 
stitutions for  mental  diseases)  for  reception,  emergency  treatment,  classification 
and  disposition  of  mental  cases  among  officers  invalided  home. 

(c)  Legislation  permitting  the  Surgeon-General  to  make  contracts  with  public  and 
private  hospitals  maintaining  satisfactory  standards  of  treatment  for  the  con- 
tinued care  of  officers  and  men  suffering  from  mental  diseases  imtil  recom- 
mended for  retirement  or  discharge  (with  or  without  pension)  by  a  special 
board. 

(d)  Appointment  of  a  special  board  of  three  medical  officers  to  ■visit  all  institutions 
in  which  insane  officers  and  men  are  cared  for  under  such  contracts  to  see  that 
adequate  treatment  is  being  given  and  to  retire  or  discharge  (with  or  without 
pension)  those  not  likely  to  recover. 

2.  War  Neuroses  ("shell  shock") 

(a)  Re-construction  centers  (the  number  and  capacity  to  be  determined  by  the 
need)  for  the  treatment  and  re-education  of  such  cases  of  war  neuroses  as  are 
invalided  home.  Injuries  to  the  brain,  cord  and  peripheral  nerves  to  be  treated 
elsewhere. 

(b)  Special  convalescent  camps  where  recovered  cases  can  go  and  not  be  subject  to 
the  harmful  influences  for  those  cases  which  exist  in  camps  for  ordinary  medical 
and  surgical  cases. 

(c)  Employment  of  the  Special  Board  of  medical  officers,  recommended  under  "  1 
(d),"  to  visit  all  re-education  centers  and  convalescent  camps  in  which  war 
neuroses  are  treated  to  see  that  adequate  treatment  is  being  given  and  to  retire 
or  discharge  (with  or  without  pension)  those  not  likely  to  recover. 

EXPEDITIONARY   FORCES 
I.    OVERSEAS 

The  plan  herein  suggested  for  dealing  with  mental  and  func- 
tional nervous  diseases  in  the  expeditionary  forces  overseas  pre- 
supposes that  all  sick  and  wounded  soldiers  who  are  not  likely  to 
be  returned  for  duty  in  the  fighting  line  within  six  months  will  be 
evacuated  to  home  territory.  The  same  considerations  which 
led  to  the  adoption  of  this  policy  by  the  Canadian  Army  are 
equally  valid  in  the  case  of  American  troops.  If  large  numbers 
of  the  sick  and  wounded  who  are  not  likely  to  return  to  active 
duty  have  to  be  cared  for  in  France  during  long  periods  of  disa- 
bility, the  amount  of  food  and  other  supplies  which  must  be  sent 
overseas  for  them  and  for  those  who  care  for  them  will  diminish 
the  tonnage  available  for  the  transportation  of  munitions  required 
for  successful  military  operations;  the  great  auxiliary  hospital 
facilities  available  in  the  United  States  cannot  be  utilized  and. 


50  MENTAL  DISEASES  AND  WAR  NEUROSES 

in  the  case  of  the  severe  neuroses,  fewer  recoveries  will  take  place. 
If  submarine  activities  seriously  interfere  with  the  return  of 
disabled  soldiers  to  the  United  States  and  it  is  necessary  to  provide 
continued  care,  chronic  cases  should  be  evacuated  to  special 
hospitals  established  in  France  for  this  purpose.  It  is  very  desir- 
able to  maintain  an  active  service  in  base  hospitals  that  receive 
cases  from  the  front.  This  is  especially  true  in  the  case  of  the  war 
neuroses. 

(a)  Base  Section  of  Lines  of  Communication.  The  base  upon 
which  each  army  rests  should  be  provided  with  a  special  base 
hospital  of  five  hundred  beds  for  neuro-psychiatric  cases.  Three 
years'  experience  in  treating  these  cases  in  general  hospitals  in 
England  and  France  amply  demonstrates  the  need  for  such  an 
institution.  Few  more  hopeful  cases  exist  in  the  medical  services 
of  the  countries  at  war  than  those  suffering  from  the  war  neuroses 
grouped  under  the  term  "shell  shock"  when  treated  in  special  hos- 
pitals by  physicians  and  nurses  familiar  with  the  nature  of  functional 
nervous  diseases  and  ivith  their  management.  On  the  other  hand, 
the  general  military  hospitals  and  convalescent  camps  presented 
no  more  pathetic  picture  than  the  mismanaged  nervous  and 
mental  cases  which  crowded  their  wards  before  such  special 
hospitals  were  established.  Exposed  to  misdirected  harshness  or 
to  equally  misdirected  sympathy,  dealt  with  at  one  time  as 
malingerers  and  at  another  as  sufferers  from  incurable  organic 
nervous  disease,  "passed  on"  from  one  hospital  to  another  and 
finally  discharged  with  pensions  which  cannot  subsequently  be 
diminished,  their  treatment  has  not  been  a  wholly  creditable 
chapter  in  military  medicine.  As  one  writer  has  said,  "they 
enter  the  hospitals  as  '  shell  shock '  cases  and  come  out  as  nervous 
wrecks."  To  their  initial  neurological  disability  (of  a  distinctly 
recoverable  nature)  are  added  such  secondary  effects  as  unfavor- 
able habit-reactions,  stereotypy  and  fixation  of  symptoms,  the 
self-pity  of  the  confirmed  hysteric,  the  morbid  timidity  and  anxiety 
of  the  neurasthenic  and  the  despair  of  the  hypochondriac.  In 
such  hospitals  and  convalescent  homes  inactivity  and  aimless 
lounging  weaken  will,  and  the  attitude  of  permanent  invalidism 
quickly  replaces  that  of  recovery.  The  provision  of  special  facil- 
ities for  the  treatment  of  "shell  shock"  cases  is  imperative  from 
the  point  of  view  of  military  efficiency  as  well  as  from  that  of 


RECOMMENDATIONS  FOR  UNITED   STATES  ARMY    51 

common  humanity,  for  more  than  half  these  cases  can  be  returned 
to  duty  if  they  receive  active  treatment  in  special  hospitals  from 
an  early  period  in  their  disease. 

British  experience  indicates  that  about  one  hundred  of  the 
beds  in  each  such  special  base  hospital  would  be  occupied  by 
mental  cases  and  the  rest  by  those  suffering  from  war  neuroses. 
It  is  not  necessary  to  make  this  division  arbitrarily  in  advance, 
however,  as  both  classes  of  cases  can  be  cared  for  in  the  type  of 
hospital  to  be  proposed  and  re-distribution  of  patients  can  be 
made  from  time  to  time  as  circumstances  require.  It  should  be 
the  object  of  these  special  base  hospitals  to  provide  treatment  for 
all  cases  likely  to  recover  and  be  returned  to  active  duty  within 
six  months.  Practically  all  mental  cases,  even  those  who  recover 
during  this  period,  as  well  as  functional  nervous  cases  presenting 
an  unfavorable  outlook  or  which  are  unimproved  by  special  treat- 
ment, should  be  evacuated  to  the  United  States  as  rapidly  as 
transportation  conditions  will  permit. 

Each  such  hospital  should  be  located  with  reference  to  its 
accessibility  to  other  hospitals  along  the  lines  of  communication 
of  the  army  which  it  serves.  This  will  necessitate  its  being  on 
the  main  railway  line  down  which  disabled  soldiers  are  evacuated 
from  the  front.  It  should  also  be  within  convenient  reach  of, 
although  not  necessarily  at,  the  port  of  embarkation.  If  it  is 
possible  to  secure  a  site  in  southern  France  where  outdoor  work 
can  be  continued  during  the  winter  many  important  advantages 
will  be  gained.  Gardening  and  other  outdoor  occupations  are  so 
valuable  that  the  amount  of  ground  adjoining  each  base  hospital, 
or  contiguous  to  it,  should  be  not  less  than  one  acre  for  every  six 
patients  of  one  third  its  population.  Thus,  at  least  thirty  acres 
are  required  for  a  hospital  with  500  beds. 

The  type  of  general  hospital  adopted  by  the  American  Army  for 
cantonment  camps  could  be  used,  with  certain  interior  changes, 
but  it  would  be  more  advantageous  to  secure  a  hotel  or  school 
and  remodel  it  to  perform  the  special  functions  of  a  hospital  of 
this  character.  The  living  arrangements  in  these  special  hospitals 
are  simpler  than  in  general  hospitals  for  medical  and  surgical 
cases.  About  five  per  cent  of  the  bed-capacity  will  have  to  be  in 
single  rooms.  This  percentage  will  be  somewhat  greater  in  the 
psychiatric  division  and  smaller  in  the  neurological  division.     Less 


52  MENTAL  DISEASES  AND  WAR  NEUROSES 

than  three  per  cent  of  the  population  will  be  bed-patients.  A 
sufficient  number  of  rooms  in  both  the  neurological  and  psychiatri- 
cal divisions  should  be  set  aside  for  officers — the  higher  proportion 
of  officers  among  patients  with  neuroses  being  taken  into  con- 
sideration in  planning  this  department. 

It  is  necessary  to  allow  hberally  for  examining  rooms,  massage, 
hydrotherapy  and  electrotherapy  and  to  provide  one  large  room 
which  can  be  used  for  an  amusement  hall.  When  the  patients 
and  staff  have  been  suitably  housed  attention  should  be  directed 
to  the  highly  important  features  of  shops,  industrial  equipment, 
gymnasium  and  gardens.  If  no  suitable  buildings  close  to  the 
hospital  can  be  secured,  perfectly  adequate  facilities  can  be 
provided  in  cheaply  constructed  wooden  huts  with  concrete  floors. 
A  gymnasium  can  be  erected  more  cheaply  than  an  existing  build- 
ing can  be  adapted  for  this  purpose  unless  a  large  storehouse,  barn 
or  factory  is  available. 

Hydrotherapeutic  equipment  should  include  continuous  baths, 
Scotch  douche,  needle  baths  and  a  swimming  pool.  The  latter  is 
exceptionally  valuable  in  the  treatment  of  functional  paralyses 
and  disturbances  of  gait  which  disappear  while  patients  are 
swimming,  thus  often  opening  the  way  for  rapid  recovery  by 
persuasion. 

Electrical  apparatus  is  necessary  for  diagnostic  purposes  and 
also  for  general  and  local  treatment. 

Second  in  importance  only  to  the  general  psychological  control 
of  the  situation  in  functional  nervous  diseases*  is  the  restoration 
of  the  lost  or  impaired  functions  by  re-education.  None  of  the 
methods  available  for  re-education  are  so  valuable  in  the  war 
neuroses  as  those  in  which  a  useful  occupation  is  employed  as  the 
means  for  training.  Re-education  should  commence  as  soon  as 
the  patient  is  received.  Thought,  will,  feeling  and  function  have 
all  to  be  restored  and  work  toward  all  these  ends  should  be  under- 
taken simultaneously.  Non-productive  occupations  are  not  only 
useless  but  deleterious.  The  principle  of  "learning  by  doing" 
should  guide  all  re-educative  work.  Continual  "resting,"  long 
periods  spent  alone,  general  softening  of  the  environment  and 
occupations  undertaken  simply  because  the  mood  of  the  patient 
suggests  them  are  positively  harmful,  as  shown  by  the  poor  re- 

*Pp.  37-38. 


RECOMMENDATIONS  FOR  UNITED   STATES  ARMY  53 

suits  obtained  in  those  general  hospitals  and  convalescent  homes 
in  which  such  measures  are  employed. 

The  industrial  equipment  needed  is  relatively  simple  and  in- 
expensive. It  is  very  desirable  to  begin  with  a  few  absolutely 
necessary  things  and  to  add  those  made  by  the  patients  them- 
selves. When  this  is  done  every  piece  of  apparatus  is  invested, 
in  the  eyes  of  the  patients,  with  the  spirit  of  achievement  through 
persistent  effort — the  very  keynote  of  treatment.  The  fact  that 
it  has  been  made  by  patients  recovering  from  neuroses  will  help 
hundreds  of  subsequent  patients  through  the  force  of  hopeful 
suggestion.  The  following  list  gives  the  equipment  for  the  shops 
which  is  necessary  at  the  beginning : 

Smiths'  shop 

Forges,  tools,  etc.,  for  ten  men 
Fitting  shop 

One  screw-cutting  lathe,  one  sensitive  drill,  one  polishing  machine,  one 
electric  motor  Ij  h.p.,  swages  and  tools  for  eight  men 
Leather  blocking  room 

Sewing  machine,  eyeletting  machine,  tank,  galvanized  iron  and  tools 
Tailors'  shop 

Three  sewing  machines,  tools  for  ten  men 
Carpenters'  shop 

Selected  tools  for  fifteen  men,  bench  screws  and  special  tools  not  for  gen- 
eral use,  wood-turner's  lathe 
Machine  shop 

Electric  motor  85  h.p.,  with  shafting,  brackets,  etc. 
Cement  shop 

Metal  moulds,  tools  for  twelve  men 
Printing  shop 

Press  and  accessories 
General 

Drilling  machine,  grindstone,  screw-cutting  lathe,  fret-saw  workers'  ma- 
chine and  patterns,  circular-saw,  bench 

Practically  all  gymnasium  apparatus  can  be  made  in  the  shops 
after  the  hospital  is  opened. 

Each  special  base  hospital  should  be  able  to  evacuate  patients 
who,  although  not  quite  able  to  return  to  active  duty,  no  longer 
require  intensive  treatment.  For  this  purpose  one  or  more  con- 
valescent camps  within  convenient  distance  by  motor  truck  from 
the  main  institution  should  be  established.  Each  of  these  con- 
valescent camps  should  not  exceed  100  in  capacity.  It  will  re- 
quire only  one  medical  officer,  one  sergeant,  three  female  nurses, 


54 


MENTAL  DISEASES  AND  WAR  NEUROSES 


an  instructor  and  three  or  four  hospital  corps  men,  as  the  patients 
will  be  able  to  care  for  themselves  and  in  a  short  time  return  to  duty. 
One  camp  may  have  to  be  established  for  the  care  of  another 
type  of  cases.  It  is  conceivable  that  submarine  activity  will  inter- 
fere so  seriously  with  the  evacuation  of  chronic  and  non-recover- 
able cases  to  the  United  States  that  the  special  hospital  will  be 
overcrowded.  Overcrowding  will  instantly  interfere  with  the 
success  of  the  work  and  this  will  simply  mean  that  men  who  other- 
wise might  recover  and  return  to  military  duty  at  the  front  will 
fail  to  do  so.  Such  a  calamity  can  be  averted  by  transferring 
chronic  and  non-recoverable  cases  to  a  camp  organized  upon  quite 
simple  lines  under  direct  control  of  the  main  hospital  and  near 
enough  to  utilize  its  therapeutic  resources.  The  beds  which 
such  patients  would  otherwise  occupy  in  the  special  base  hospital 
can  be  made  available  for  the  use  of  fresh,  recoverable  cases. 
Such  developments  might  better  be  made  naturally  as  circum- 
stances require  than  provided  for  by  any  formal  arrangements 
made  in  advance. 

Each  base  hospital  should  have  the  personnel  enumerated  in 
the  following  table : 


PERSONNEL   FOR   SPECIAL   BASE   HOSPITAL   FOR    NEURO- 
PSYCHIATRIC  CASES 


Commissioned  Officers 

Major 

M.C. 

Commanding  Officer 

Captain 

M.C. 

Adjutant,  Surgeon  of  the  Command,  Recruiting 
Officer 

Captain 

Q.C. 

Quartermaster 

Major 

M.R.C. 

Director 

Major 

M.R.C. 

Chief  Neurological  Division 

Major 

M.R.C. 

Chief  Psychiatrical  Division 

Major 

M.R.C. 

Chief  Occupational  Division 

Captain 

M.R.C. 

Pathologist 

Captain 

M.R.C. 

In  charge  of  Convalescent  Camp 

Captain 

M.R.C. 

In  charge  of  Electrotherapy  and  Hydrotherapy 

Captain 

M.R.C. 

Ward  Physician  (in  charge  of  Transportation  of 
Patients) 

Captain 

M.R.C. 

Ward  Physician 

Captain 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

M.R.C. 

Ward  Physician 

1st  Lieutenant 

San.C. 

Psychologist 

1st  Lieutenant 

San.C. 

Registrar 

RECOMMENDATIONS  FOR  UNITED  STATES  ARMY    55 


NON-COMMISSIONED  OFFICERS 

Sergeant, 

1st  CI. 

H.C. 

General  Supervision 

Sergeant, 

1st  CI. 

Q.C. 

Quartermaster  Sergeant 

Sergeant, 

1st  CI. 

H.C. 

Office 

Sergeant, 

1st  CI. 

H.C. 

In  charge  of  Detachment  and  Detachment  Accounts 

Sergeant, 

1st  CI. 

H.C. 

In  charge  of  Mess  and  Kitchen 

Sergeant, 

1st  CI. 

H.C. 

General  Supervision,  Convalescent  Camp 

Sergeant, 

1st  CI. 

H.C. 

In  charge  of  Shops 

Sergeant, 

1st  CI. 

H.C. 

In  charge  of  Garden  and  Grounds 

Sergeant 

H.C. 

Hydrotherapy  Rooms 

Sergeant 

H.C. 

Electrotherapy  Rooms 

Sergeant 

H.C. 

Massage  Rooms 

Sergeant 

H.C. 

Shops 

Sergeant 

H.C. 

Gymnasium 

Sergeant 

H.C. 

Mess  and  Kitchen 

Sergeant 

H.C. 

Storerooms 

Sergeant 

H.C. 

Office 

Sergeant 

H.C. 

Office 

Sergeant 

H.C. 

Outside  Police 

Sergeant 

H.C. 

Wards 

Sergeant 

H.C. 

Wards 

Sergeant 

H.C. 

Wards 

Sergeant 

H.C. 

Wards 

Sergeant 

H.C. 

Wards 

Sergeant 

H.C. 

Transportation  of  Patients 

Femai^  Nubses  (N.C.^ 

.       Chief  Nurse 

1 

^.  ^  Assistant  to  Chief  1 
,       Dietist 

*furse.  .  . 

1 

1 

46 

Ward  Nurses 

43 

Enusted  Men  (H.C.) 
14  Acting  Cooks 

115  Privates,  1st  CI.  and  Privates 
Distributed  as  follows: 
Ward  Attendants 

Neurological  Division ii    ] 

Psychiatrical  Division 26     [  52 

Convalescent  Camp 4    J 

Shops 10 

Electrotherapy  rooms 4 

Hydrotherapy  rooms 4 

Massage  rooms 6 

Laboratory 2 

Kitchens  and  mess 14 

Office 5 

Storerooms 6 

Orderlies 4 

Outside  Police 4 

Supernumeraries 4 


115 


8 


56  MENTAL  DISEASES  AND  WAR  NEUROSES 

Civilian  Emplotees 
Instructors 

Outdoor  occupations 

Indoor  occupations 

Assistant  Instructors 

Carpentry  and  wood  carving 

Cement  work 

Metal  work 

Leather  work 

Gardening 

Printing 

Gymnasium 2 

Stenographers 4 

Photographer 1 

Laboratory  technician 1 

16 
Recapitulation 

Commissioned  officers 20 

Non-commissioned  officers 24 

Female  nurses 46 

Enlisted  men 129 

Civilian  employees 16 

235 

The  commissioned  medical  officers  should  all  be  men  with  ex- 
cellent training  in  neurology  and  psychiatry.  The  neurologists 
should  have  a  psychiatrical  outlook  and  the  psychiatrists  should 
be  familiar  with  neurological  technique.  Of  importance  almost 
equal  to  the  professional  qualifications  of  these  officers  is  their 
character  and  tact,  and  no  man  who  is  unable  to  adjust  his  per- 
sonal problems  should  be  selected  for  this  work.  There  is  no 
place  in  such  hospital  for  a  "queer,"  disgruntled  or  irritable 
individual  except  as  a  patient.  Men  who  are  strong,  forceful, 
patient,  tactful  and  sympathetic  are  required.  It  is  better  to 
permit  a  medical  officer  not  having  these  qualifications  to  remain 
at  home  than  to  assign  him  to  one  of  these  hospitals  and  allow 
him  to  interfere  with  treatment  by  his  failure  to  establish  and 
maintain  proper  contact  with  his  patients.  The  resources  to  be 
employed  include  psychological  analysis,  persuasion,  sympathy, 
discipline,  hypnotism,  ridicule,  encouragement  and  severity. 
All  are  dangerous  or  useless  in  the  hands  of  the  inexperienced,  as 
the  records  of  "shell  shock"  cases  treated  in  general  hospitals  tes- 
tify.    In  the  hands  of  men  capable  of  forming  a  correct  estimate 


RECOMMENDATIONS  FOR  UNITED  STATES  ARMY    57 

of  the  make-up  of  each  patient  and  of  employing  these  resources 
with  reference  to  the  therapeutic  problem  presented  by  each  case, 
they  are  powerful  aids. 

The  female  nurses  should  have  had  experience  in  the  treatment 
of  mental  and  nervous  diseases.  Character  and  personality  are 
as  important  in  nurses  as  in  medical  officers.  A  large  proportion 
of  college  women  will  be  found  advantageous. 

The  enlisted  men  who  perform  the  duties  of  ward  attendants 
and  assistants  in  the  shops,  gardens  and  gymnasium  should  in- 
clude a  considerable  number  of  those  who  have  had  experience  in 
dealing  with  mental  and  nervous  diseases.  The  civilian  employees 
who  act  as  instructors  should  all  have  had  practical  experience 
in  the  use  of  occupations  in  the  treatment  of  nervous  and  mental 
diseases.  The  instructor  for  bed  occupations  should  be  a  woman 
and  she  should  train  the  female  nurses  to  assist  her  in  this  kind  of 
work. 

No  work  is  more  exacting  than  that  which  will  fall  to  the  phy- 
sicians and  chief  lay  employees  in  such  hospital.  Success  in 
treatment  depends  chiefly  upon  each  person's  establishing  and 
maintaining  a  sincere  belief  in  the  work  to  which  he  or  she  is 
assigned.  No  hysterical  case  must  be  regarded  as  hopeless.  The 
maintenance  of  a  correct  attitude  and  constant  co-operation  be- 
tween physicians,  nurses,  instructors  and  men  in  the  face  of  the 
tremendous  demands  which  neurotic  patients  make  upon  the 
patience  and  resourcefulness  of  those  treating  them  soon  bring 
weariness  and  loss  of  interest  if  opportunities  for  recreation  do  not 
exist.  Therefore,  it  should  be  the  duty  of  the  director  to  see  that 
the  morale  and  good  spirits  of  all  are  kept  up.  His  recommenda- 
tions as  to  the  transfer  to  other  military  duties  of  medical  officers, 
nurses,  instructors  or  men  who  prove  unsuited  for  this  work 
should  be  acted  upon  whenever  possible  by  the  chief  surgeon  under 
whom  the  hospital  serves.  A  man  or  a  woman  may  prove  un- 
adapted  to  this  work  and  yet  be  a  valuable  member  of  the  staff  of 
another  kind  of  hospital.  This  subject  is  mentioned  so  particu- 
larly because  of  its  great  importance.  The  type  of  personnel  will 
determine  the  success  of  this  hospital  and  hence  its  usefulness  to 
the  army  in  a  measure  which  is  unknown  in  other  military  hos- 
pitals. It  does  not  greatly  matter  whether  the  operating  surgeon 
understands  the  personality  of  the  soldier  upon  whom  he  is  oper- 


58  MENTAL  DISEASES  AND  WAR  NEUROSES 

ating  or  not.  Whether  or  not  the  physician  treating  a  case  of 
"shell  shock"  understands  the  personality  of  his  patient  spells 
success  or  failure. 

The  first  special  base  hospital  established  for  neuro-psychiatric 
cases  should  have  so  highly  eflficient  a  personnel  that  it  will  be 
able  to  contribute  one  third  of  its  medical  oflBcers  and  trained 
workers  to  the  next  similar  base  hospital  to  be  established,  filling 
their  places  from  those  on  its  reserve  list.  This  should  be  re- 
peated a  second  time  if  necessary  and  thus  a  uniform  standard  of 
excellence  and  the  same  general  approach  to  problems  of  treat- 
ment assured  in  each  special  base  hospital  organized  in  France. 

(b)  Advanced  Section  of  Lines  of  Communication.  The  French 
and  the  British  experience  shows  the  great  desirability  of  institut- 
ing treatment  of  "shell  shock "  cases  as  early  as  possible.  So  little 
has  been  done  as  yet  in  this  direction  that  we  do  not  know  much 
about  the  onset  of  these  cases  and  just  what  happens  during  the 
first  few  days.  Such  information  as  has  been  contributed,  how- 
ever, by  the  few  neurologists  and  psychiatrists  who  have  had  an 
opportunity  of  working  in  casualty  clearing  stations  or  positions 
even  nearer  the  front  indicates  that  much  can  be  done  in  dealing 
with  these  cases  if  they  can  be  treated  within  a  few  hours  after  the 
onset  of  severe  nervous  symptoms.  There  are  data  to  show  that 
even  by  the  time  these  cases  are  received  at  base  hospitals  ad- 
ditions have  been  made  to  the  initial  neurological  disability  and  a 
coloring  of  invahdism  given  which  frequently  influences  the  pros- 
pects of  recovery.  It  is  desirable,  therefore,  to  provide  neuro- 
psychiatric  wards  for  selected  base  hospitals  in  the  advanced 
section  of  the  lines  of  communication.  Other  base  hospitals  can 
send  cases  to  those  which  possess  such  wards.  The  plan  of  pro- 
viding such  sections,  in  charge  of  neurologists  and  psychiatrists, 
for  divisional  base  hospitals  in  the  cantonment  camps  in  the  United 
States  has  been  adopted  by  the  Surgeon-General.  If  it  is  found 
practicable  to  make  similar  provisions  in  France,  these  units  can 
accompany  the  divisions  to  which  they  are  attached  when  they 
join  the  expeditionary  forces  in  the  spring  of  1918.  In  the  mean- 
time it  is  essential  that  each  base  hospital  should  have  on  its 
staff  a  neurologist  or  a  psychiatrist.  Provision  for  the  care  of 
mental  and  nervous  cases  nearer  the  front,  along  the  lines  of  com- 
munication, can  best  be  developed,  after  the  first  special  base 


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RECOMMENDATIONS  FOR  UNITED   STATES  ARMY    59 

hospital  for  neuro-psychiatric  cases  has  been  estabhshed,  by  de- 
taching from  its  staff  individual  officers  as  actual  circumstances 
require. 

It  is  undesirable  to  formulate  plans  for  providing  this  kind  of 
care  still  nearer  the  fighting  line  until  a  more  careful  study  has  been 
made  of  the  results  obtained  by  the  English  and  French  medical 
services  in  this  undertaking. 

The  foregoing  recommendations  are  illustrated  graphically  in 
the  upper  part  of  the  accompanying  chart  from  Major  Pearce 
Bailey's  recent  paper.* 

II.    IN    THE    UNITED    STATES 

(a)  Mental  Diseases  (Insanity).  If  the  policy  is  adopted  of 
caring  in  France  for  mental  cases  likely  to  recover  and  evacuating 
all  others  to  the  United  States  at  once  or  at  the  expiration  of  six 
months'  treatment,  we  may  expect  to  receive  at  the  port  of  ar- 
rival in  the  United  States  not  less  than  250  insane  soldiers  per 
month  from  an  expeditionary  force  of  1,000,000.  We  may  as- 
sume that  a  plan  will  be  adopted  for  the  reception  and  the  dis- 
tribution of  soldiers  invalided  from  France  such  as  proposed  by 
Major  Bailey. 

Well-organized  facilities  for  deaHng  with  mental  disease  exist 
in  the  United  States  which  can  be  utilized  by  the  government 
without  the  necessity  of  creating  expensive  new  agencies.  It  is 
obvious  that  the  first  facts  to  be  determined  in  the  case  of  soldiers 
reaching  the  United  States  while  still  suffering  from  mental  dis- 
orders or  who  have  been  invalided  home  after  recovery  from 
acute  attacks,  are: 

1.  The  cause  of  the  disorder,  with  special  reference  to  military  service. 

2.  The  probable  outcome. 

3.  The  probable  duration. 

4.  The  special  needs  in  treatment. 

It  is  quite  impossible  to  ascertain  any  of  these  facts  by  casual 
examination  and  so  it  will  be  necessary  to  provide  "clearing  hos- 
pitals" for  non-commissioned  officers  and  enlisted  men  where 
patients  may  be  received  and  studied  upon  their  arrival  with  the 
view  of  determining  these  questions.  With  an  average  annual 
admission  rate  of  3,000  patients,  a  clearing  hospital  of  three 

•Mental  Htgiene,  Vol.  I,  No.  3  (July.  1917). 


58 


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RECOMMENDATIONS  FOR  UNITED  STATES  ARMY    59 

hospital  for  neuro-psychiatric  cases  has  been  established,  by  de- 
taching from  its  staff  individual  officers  as  actual  circumstances 
require. 

It  is  undesirable  to  formulate  plans  for  providing  this  kind  of 
care  still  nearer  the  fighting  line  until  a  more  careful  study  has  been 
made  of  the  results  obtained  by  the  English  and  French  medical 
services  in  this  undertaking. 

The  foregoing  recommendations  are  illustrated  graphically  in 
the  upper  part  of  the  accompanying  chart  from  Major  Pearce 
Bailey's  recent  paper.* 

V 

II.    IN   THE   UNITED    STATES 

(a)  Mental  Diseases  {Insanity).  If  the  policy  is  adopted  of 
caring  in  France  for  mental  cases  likely  to  recover  and  evacuating 
all  others  to  the  United  States  at  once  or  at  the  expiration  of  six 
months'  treatment,  we  may  expect  to  receive  at  the  port  of  ar- 
rival in  the  United  States  not  less  than  250  insane  soldiers  per 
month  from  an  expeditionary  force  of  1,000,000.  We  may  as- 
sume that  a  plan  will  be  adopted  for  the  reception  and  the  dis- 
tribution of  soldiers  invalided  from  France  such  as  proposed  by 
Major  Bailey. 

Well-organized  facilities  for  dealing  with  mental  disease  exist 
in  the  United  States  which  can  be  utilized  by  the  government 
without  the  necessity  of  creating  expensive  new  agencies.  It  is 
obvious  that  the  first  facts  to  be  determined  in  the  case  of  soldiers 
reaching  the  United  States  while  still  suffering  from  mental  dis- 
orders or  who  have  been  invalided  home  after  recovery  from 
acute  attacks,  are: 

1.  The  cause  of  the  disorder,  with  special  reference  to  military  service. 

2.  The  probable  outcome. 

3.  The  probable  duration. 

4.  The  special  needs  in  treatment. 

It  is  quite  impossible  to  ascertain  any  of  these  facts  by  casual 
examination  and  so  it  will  be  necessary  to  provide  "clearing  hos- 
pitals" for  non-commissioned  officers  and  enlisted  men  where 
patients  maj^  be  received  and  studied  upon  their  arrival  with  the 
view  of  determining  these  questions.  With  an  average  annual 
admission  rate  of  3,000  patients,  a  clearing  hospital  of  three 

*Mkntal  Hygiene,  Vol.  I,  No.  3  (July,  1917). 


60  MENTAL  DISEASES  AND  WAR  NEUROSES 

hundred  beds  would  permit  an  average  period  of  treatment  of 
thirty-six  days.  This  would  seem  to  be  sufficient  as  the  Boston 
Psychopathic  Hospital,  during  an  average  period  of  treatment  of 
eighteen  days,  not  only  determines  similar  questions  but  provides 
continued  care  for  a  considerable  number  of  recoverable  cases. 
Such  clearing  hospitals  should  be  established  near  the  port  of 
arrival  and  should  be  essentially  military  hospitals,  with  directors 
who  are  not  only  well  trained  in  their  medical  duties  but  are 
familiar  with  the  requirements  of  military  life  and  with  the 
institutional  provisions  in  the  United  States  that  can  be  utilized 
for  continued  treatment. 

With  such  active  service  as  a  clearing  hospital  mil  have,  the 
number  of  medical  officers  should  be  not  less  than  ten  and  there 
should  be  an  adequate  clerical  force  to  care  for  the  important 
administrative  matters  which  would  require  attention.  The 
organization  of  civil  psychopathic  hospitals  in  this  country 
affords  data  for  determining  the  proper  size  of  the  ward  and 
domestic  services. 

After  a  period  of  observation  and  treatment  the  director  of 
such  hospital  should  be  prepared  to  furnish  the  Special  Dis- 
tributing Board  with  information  and  definite  recommendations 
as  to  the  further  disposal  of  each  case. 

Some  patients  will  be  found  at  the  clearing  hospitals  to  have 
recovered.  Although,  as  a  matter  of  military  policy,  these 
patients  will  not  be  available  for  duty  again  in  France,  they  are 
still  of  military  value  to  the  government.  Such  soldiers  should 
be  returned  to  duty  in  the  United  States  by  the  Special  Distribut- 
ing Board  in  a  category  which  would  prevent  their  being  exposed 
again  in  the  fighting  line  but  which  would  indicate  precisely  the 
work  for  which  they  are  suited.  We  can  conceive  of  many  such 
soldiers  who  are  likely  to  break  down  again  under  the  stress  of 
actual  fighting  but  who  are  quite  likely  to  remain  in  good  health 
if  they  are  not  so  exposed.  These  men  will  have  had  valuable 
military  experience  and  could  render  efficient  service  as  instructors 
in  training  camps  or  in  the  performance  of  other  military  duties 
in  the  United  States.  Others  who  have  recovered  will  give 
evidence  of  possessing  such  an  unstable  or  inferior  mental  make-up 
that  no  further  military  life,  even  in  the  United  States,  is  desirable. 
In  such  cases,  recommendations  should  be  made  by  the  directors 


RECOMMENDATIONS  FOR  UNITED  STATES  ARMY   61 

of  the  clearing  hospitals  to  the  Special  Distributing  Board  to 
discharge  them  to  their  homes,  with  or  without  pensions  as  the 
circumstances  demand. 

There  will  be  found  others  who  have  not  been  benefited  at  all 
by  treatment  in  France  and  who  suffer  from  mental  disorders 
with  an  extremely  unfavorable  outlook  for  recovery.  When  this 
conclusion  seems  justified,  the  directors  of  the  clearing  hospitals 
should  recommend  these  cases  for  transfer  to  a  suitable  public 
or  private  institution  in  the  states  from  which  they  enlisted 
and  their  discharge  from  the  army,  with  or  without  pension  as 
the  circumstances  demand. 

Another  group  of  cases  will  be  made  up  of  those  suffering  from 
psychoses  which  are  probably  recoverable.  It  is  equally  to  the 
advantage  of  the  army,  the  community  and  the  patient  that 
such  soldiers  be  given  continued  treatment.  Facilities  for  the 
care  of  mental  diseases  vary  so  greatly  in  many  of  the  states  that 
neither  the  army  nor  the  patients  can  receive  any  assurance  that 
proper  treatment  will  be  afforded  if  such  soldiers  are  discharged 
to  the  public  institution  nearest  their  homes.  In  such  cases  the 
important  question  of  discharge,  with  or  without  pension,  should 
be  deferred  until  every  facility  has  been  given,  during  a  reasonable 
period  of  time,  for  recovery  to  take  place.  It  is  recommended, 
therefore,  that  these  cases  be  retained  in  the  army  until  their 
recovery  or  until  the  end  of  the  war  and  ordered  for  treatment  to 
state  hospitals  with  which  the  Secretary  of  War  has  made  con- 
tracts. A  government  hospital  for  the  insane  would  be  the  most 
suitable  for  carrying  out  such  treatment  but  the  present  excellent 
institution  in  Washington  has  reached  the  size  of  3,135  beds  and 
can  care  for  few  additional  military  cases.  It  is  highly  desirable 
that  the  government  should  now  establish  a  military  hospital 
for  mental  diseases  for  the  army  and  navy  and  permit  the  govern- 
ment hospital  to  devote  all  its  resources  to  its  civil  duties.  It 
would  be  impossible,  however,  to  have  such  institution  ready 
within  two  years.  If  it  were  possible  to  construct  such  new 
government  hospital  in  a  shorter  time,  it  would  still  be  necessary 
to  provide  for  treatment  by  contract,  for  this  institution  would 
probably  have  to  care  for  not  more  than  1,500  military  cases 
during  peace.  A  much  larger  number  is  to  be  expected  during 
the  war. 


62  MENTAL  DISEASES  AND  WAR  NEUROSES 

It  is  wiser  to  care  for  insane  soldiers  during  the  war  under  con- 
tract at  ten  or  twelve  first-class  hospitals  with  fully  adequate 
facilities  for  treatment  than  to  distribute  them  solely  with  refer- 
ence to  the  location  of  their  homes.  This  will  involve  a  certain 
hardship  through  making  it  difficult  for  such  men  to  be  visited 
by  their  relatives  and  friends  but  it  is  possible  to  distribute  the 
contract  hospitals  over  the  country  in  such  way  that  there  would 
be  few  cases  more  than  a  day's  journey  from  their  homes.  The 
primary  object  is  to  insure  recovery  in  all  recoverable  cases. 
This  should  outweigh  all  other  considerations. 

The  legislation  permitting  the  Secretary  of  War  to  make  such 
contracts  should  state  clearly  that  they  shall  be  made  only  with 
institutions  possessing  facilities  for  treatment  laid  down  by  the 
Surgeon-General.  A  list  of  such  facilities,  prepared  by  The  Na- 
tional Committee  for  Mental  Hygiene  for  another  purpose,  is 
appended*  as  it  may  form  a  useful  guide  in  this  connection.  The 
contract  hospitals  should  be  required  to  devote  an  entire  building 
of  approved  construction  to  military  cases  or  to  erect  temporary 
structures  meeting  the  necessary  requirements  for  this  purpose. 

In  order  that  the  army  may  be  able  to  discharge  mental  cases 
cared  for  under  contract  promptly  upon  their  recovery  or  upon 
ascertaining  that  recovery  is  unlikely,  it  is  desirable  that  a  special 
board  of  three  medical  officers  should  be  established  to  visit  the 
institutions  constantly  and  act  as  a  Board  of  Survey.  If  a 
medical  officer  in  each  contract  hospital  were  appointed  in  the 
Medical  Reserve  Corps  and  assigned  to  the  duty  of  caring  for 
army  patients  he  could  serve  as  a  member  of  such  board  when 
convened  at  his  hospital  and  make  it  possible  for  the  three  general 
members  to  cover  much  more  ground. 

Clearing  wards  for  officers  should  be  established  to  serve  the 
special  purposes  indicated  in  the  description  of  the  clearing  hos- 
pitals for  enlisted  men.  Such  wards  should  provide  for  the  recep- 
tion, classification,  and  treatment  in  cases  likely  to  be  of  short 
duration.  They  might  be  established  in  connection  with  general 
hospitals  at  the  port  of  arrival  or  in  connection  with  very  effi- 
cient private  institutions  for  the  insane  in  which  full  military 
control  of  this  department  could  be  secured. 

It  is  equally  important  to  provide  for  the  continued  treatment 

*Appendix  IV. 


RECOMMENDATIONS  FOR  UNITED   STATES  ARMY  63 

of  officers  and  not  to  leave  this  question,  in  which  the  army  has  so 
great  an  interest,  to  choice  or  geographical  convenience.  Arrange- 
ment similar  to  those  for  the  continued  care  of  enlisted  men  in 
public  contract  hospitals  could  easily  be  made  with  the  best, 
endowed  private  institutions  for  the  insane. 

(b)  War  Neuroses  {"Shell  Shock").  It  is  not  necessary  here  to 
outline  the  organization  of  reconstruction  centers  for  the  treat- 
ment of  war  neuroses  in  the  United  States.  The  general  prin- 
ciples in  treatment  described  in  the  foregoing  report  and  in  the 
plan  recommended  for  France  should  be  a  guide  in  the  develop- 
ment of  those  centers. 

It  should  be  remembered  that  if  the  policy  recommended  of 
evacuating  to  the  United  States  only  the  patients  who  fail  to 
recover  in  six  months  in  France  is  adopted,  some  very  intracta- 
ble cases  will  be  received.  For  the  most  part  these  will  be  patients 
with  a  constitutional  neuropathic  make-up — the  type  most  fre- 
quently seen  in  civil  practice.  Many  of  these  cases  will  prove 
amenable  to  long-continued  treatment  and  much  can  be  expected 
from  the  mental  effect  of  return  to  the  United  States.  It  is  very 
important  not  to  fall  into  the  mistake  made  in  England  of  dis- 
charging these  severe  cases  with  a  pension  because  of  the  discour- 
aging results  of  treatment.  To  do  so  will  swell  the  pension  list 
enormously,  as  can  be  seen  by  the  fact  that  15  per  cent  of  all 
discharges  from  the  British  Army  are  unrecovered  cases  of  mental 
diseases  and  war  neuroses.  Quite  aside  from  financial  considera- 
tions, however,  is  the  injustice  of  turning  adrift  thousands  of 
young  men  who  developed  their  nervous  disability  through  mili- 
tary service  and  who  can  find  in  their  home  towns  none  of  the 
facilities  required  for  their  cure.  It  is  recommended,  therefore, 
that  no  soldiers  suffering  from  functional  nervous  diseases  be  dis- 
charged from  the  army  until  at  least  a  year's  special  treatment  has 
been  given.  Furloughs  can  be  given  when  visits  home  or  treat- 
ment in  civil  hospitals  will  be  beneficial  but  the  government 
should  neither  evade  the  responsibility  nor  surrender  the  right  to 
direct  the  treatment  of  these  cases.  A  serious  social  and  eco- 
nomic problem  has  been  created  in  England  already  through  the 
establishment  in  its  communities  of  a  group  of  chronic  nervous 
invalids  who  have  been  prematurely  discharged  from  the  only 
hospitals  existing  for  the  efficient  treatment  of  their  illness.     So 


64  MENTAL  DISEASES  AND  WAR  NEUROSES 

serious  is  this  problem  that  a  special  sanitarium  "The  Home  of 
Recovery"* — the  first  of  several  to  be  provided — has  been  estab- 
lished in  London  and  subsidized  by  the  War  Ofiice  for  the  treat- 
ment of  such  cases  among  pensioners. 

It  is  highly  important  not  to  permit  convalescent  cases  of  this 
kind  to  be  cared  for  in  the  ordinary  type  of  convalescent  camp  or 
home.  The  surroundings  so  suitable  for  convalescents  from 
wounds  or  other  diseases  are  very  harmful  to  neurotic  cases. 
Here  much  that  has  been  accomplished  in  special  hospitals  by 
patient,  skilful  work  is  undone.  Therefore,  special  convalescent 
camps  similar  to  those  recommended  for  the  expeditionary  forces 
in  France  should  be  established  within  convenient  reach  of  the 
reconstruction  centers. 

The  special  board  recommended  for  the  final  disposition  of 
mental  cases  should  deal  with  cases  of  functional  nervous  diseases. 

NON-EXPEDITIONARY   FORCES 

Facilities  for  the  treatment  of  neuro-psychiatric  cases  at  the 
camps  in  the  United  States  have  been  approved  by  the  Surgeon- 
General  and  are  now  being  provided.  These  will  undoubtedly 
prove  sufficient  for  dealing  temporarily  with  mental  cases  devel- 
oping in  the  non-expeditionary  forces.  Their  final  disposition 
should  be  made  by  means  of  the  same  mechanism  recommended 
for  expeditionary  patients  who  are  invalided  home,  except  that 
the  functions  of  the  clearing  hospital  for  mental  diseases  can  be 
performed  by  the  neuro-psychiatric  wards  of  divisional  hospitals 
and  that  of  the  special  board  by  the  Board  of  Survey  composed 
of  the  neurologists  and  psychiatrists  stationed  at  the  camps. 

Neuroses  are  very  common  among  soldiers  who  have  never 
been  exposed  to  shell  fire  and  will  undoubtedly  be  seen  frequently 
among  non-expeditionary  troops  in  this  country.  In  England 
nearly  30  per  cent  of  all  men  from  the  home  forces  admitted  to 
one  general  hospital  were  suffering  from  various  neuroses. f 
Most  of  these  were  men  of  very  neurotic  make-up.  Many  had  had 
previous  nervous  breakdowns.  Fear,  even  in  the  comparatively 
harmless  camp  exercises,  was  a  common  cause  of  neurotic  symp- 

*AppeiKlix  III. 

fBurlon-Fanning,  F.  W.  Neurasthenia  in  soldiers  of  the  home  forces.  Lancet 
(London).     1 :  907-11  (June  16,  1917). 


RECOMMENDATIONS  FOR  UNITED  STATES  ARMY   65 

toms.  Heart  symptoms  were  exceedingly  common.  The  same 
experience  in  our  own  training  camps  can  be  confidently  predicted. 
The  responsibility  of  the  government  in  such  cases  is  obviously 
diflterent  from  that  in  soldiers  returning  from  duty  abroad.  In 
the  neuro-pyschiatric  wards  of  divisional  hospitals  the  important 
and  difficult  question  of  diagnosis  can  be  well  determined.  Most 
such  cases  should  be  discharged  from  the  service.  Some  can  be 
treated  at  the  reconstruction  centers  for,  unfortunately,  there  are 
scarcely  any  provisions  in  the  United  States  for  the  treatment  of 
the  neuroses  except  in  the  case  of  the  rich.  It  is  freely  predicted 
in  England  that  the  wide  prevalence  of  the  neuroses  among  soldiers 
will  direct  attention  to  the  fact  that  this  kind  of  illness  has  been 
almost  wholly  ignored  while  great  advances  have  been  made  in 
the  treatment  of  all  others.  In  civil  life  one  still  hears  of  de- 
tecting hysteria,  as  if  it  were  a  crime  and,  although  the  wounded 
burglar  is  carefully  and  humanely  treated  in  the  modern  city 
hospital,  the  hysteric  is  usually  driven  away  from  its  doors. 
Today  the  enormous  number  of  these  cases  among  some  of 
Europe's  best  fighting  men  is  leading  to  a  revision  of  the  medical 
and  popular  attitude  toward  functional  nervous  diseases. 


APPENDICES 


I.  REFERENCES  EST  ENGLISH  TO  MENTAL  DISEASES  AND  WAR 
NEUROSES  ("SHELL  SHOCK")  AND  THEIR  TREATMENT  AND 
MANAGEMENT 


n.    THE  USE  OF  INSTITUTIONS  FOR  THE  INSANE  AS  MILITARY  HOS- 
PITALS 


m.  SPECIAL   MILITARY   HOSPITALS   FOR   MENTAL   DISEASES    AND 
WAR  NEUROSES  ("SHELL  SHOCK") 

1.  DiHECTOBT 

2.  Deschiption  op  Hospitals  Visited 

rV.  FACILITIES  NEEDED  FOR  EFFICIENT  TREATMENT  OF  MENTAL 
DISEASES  IN  A  MODERN  PUBLIC  INSTITUTION 


APPENDIX  I 

REFERENCES  IN  ENGLISH  TO  MENTAL  DIS- 
EASES    AND    WAR    NEUROSES     ("SHELL 
SHOCK")   AND  THEIR  TREATMENT 
AND  MANAGEMENT 

This  bibliography  includes  only  books,  articles  and  other  refer- 
ences published  since  the  beginning  of  the  war.  Abstracts  of 
some  of  the  more  important  articles  in  English,  French,  German, 
Italian  and  Russian  periodicals  were  published  in  Mental  Hy- 
giene, Vol.  I,  No.  3,  July,  1917.  A  complete  review  of  the  lit- 
erature on  the  psychoses  and  neuroses  in  war  will  be  published 
as  a  monograph  by  the  War  Work  Committee  of  The  National 
Committee  for  Mental  Hygiene  in  March,  1918. 


APPENDIX  I 

REFERENCES  IN  ENGLISH  TO  MENTAL  DISEASES  AND  WAR 

NEUROSES  ("SHELL  SHOCK")  AND  THEIR  TREATMENT 

AND   MANAGEMENT 

1.  Abrahams,  Adolphe.     Case  of  hysterical  paraplegia.     J.  of  Roy. 

army  med.  corps  24:  471-73,  May  1915. 

2.  Abrahams,  Adolphe.     Soldier's  heart.    Lancet,  Lond.,  March  24, 

1917,  p.  442-45. 

3.  Adler,  Herman  M.     The  greater  psychiatry  and  the  war.     Mental 

hygiene  1:  364-65,  July  1917. 

4.  Adrian,  E.  D.,  and  Yealland,  L.  R.    Treatment  of  some  common 

war  neuroses.    Lancet,  Lond.,  June  9,  1917,  p.  867-72. 

5.  Armstrong-Jones,  Robert.     Psychology  of  fear  and  effects  of  panic 

fear  in  war-time.     J.  of  ment.  science,  Lond.,  63:346-89,  July 
1917. 

6.  The  army  and  mental  disease  (Editorial)     J.  of  Amer.  med.  assoc. 

63:  1396-97,  Oct.  17,  1914. 

7.  Auer,  E.  Murray.     Some  of  the  nervous  and  mental  conditions 

arising  in  the  present  war.     Mental  hygiene  1:  383-88,  July 
1917. 

8.  Auer,  E.  Murray.     Phenomena  resultant  upon  fatigue  and  shock 

of  the  central  nervous  system  observed  at  the  front  in  France. 
Med.  rec.  89:  641-44,  April  8,  1916. 

9.  Bailey,    Pearce.     Care    of    disabled    returned    soldiers.     Mental 

hygiene  1:  345-53,  July  1917. 

10.  Bailey,  Pearce.     Psychiatry  and  the  army.     Harper's  mag.   90: 

252-57,  July  1917. 

11.  Ballard,  E.  Fryer.     Epitome  of  mental  diseases.    Lond.,  Churchill, 

1917.     244  p.  illus.     Pt.  2. 

12.  Ballard,  E.  Fryer.     Some  notes  on  battle  psychoneuroses.     J.  of 

ment.  science,  Lond.,  63:  400-05,  July  1917. 

13.  Barker,  Lewellys  F.     War  and  the  nervous  system;  address  deliv- 

ered at  the  annual  meeting  of  the  American  neurological  associa- 
tion, 1916.  J.  of  nerv.  and  ment.  dis.  44:  1-10,  July  1916. 
^4.  Batten,  F.  E.  Some  functional  nervous  affections  produced  by 
the  war.  Quar.  j.  med.,  Lond.,  9:  73-82,  Jan.  1916. 
15.  Beaton,  Thomas.  Some  observations  on  mental  conditions  as 
observed  amongst  the  ship's  company  of  a  battleship  in  war  time. 
J.  of  Roy.  nav.  med.  service  1:  447-52,  Oct.  1915. 


70  MENTAL  DISEASES  AND   WAR  NEUROSES 

16.  Bruce,  A.  Ninian.     Treatment  of  functional  blindness  and  func- 

tional loss  of  voice.     Rev.  of  neurol.  and  psychiatry,  Edin.,  14: 
195-98,  1916. 

17.  Burton-Fanning,   F.   W.     Neiu-asthenia  in  soldiers  of  the  home 

forces.    Lancet,  Lond.,  June  16,  1917,  p.  907-11.    Report  to 
the  Medical  research  committee. 

18.  Buzzard,  E.  Farquhar.     Warfare  on  the  brain.     Lancet,  Lond., 

Dec.  30,  1916,  p.  1095-99. 

19.  Campbell,  A.  W.     Remarks  on  some  neuroses  and  psychoses  in 

war.     Med.  j.  of  Australia,  April  15,  1916,  p.  319. 

20.  Campbell,   Harry  W.     War  neuroses.     Practitioner,   Lond.,   96: 

501-09,  May  1916. 

21.  Campbell,  Kenneth.     Case  of  hysterical  amblyopia.     Brit.  med. 

j.,  Sept.  18,  1915,  p.  434. 

22.  Clarke,  J.  Michell.     Some  neuroses  of  the  war.     Bristol  med.- 

chir.  j.  34:  49-72,  July  1916;  also  in  Clin.  j.  45:  381  and  395,  Nov. 
1,  1916. 

23.  Craig,  Maurice.     Psychological  medicine.     3ded.     Lond.,  Church- 

ill,   1917.     496    p.  illus.     Chapters    15:   254-60;     16:    287-92; 
18:  300-11. 

24.  Culpin,  M.     Practical  hints  on  functional  disorders.     Brit.  med. 

j.,  Oct.  21,  1916,  p.  548-49. 

25.  Dawson,  G.  de  H.     Case  of  shell  concussion;  treatment  by  general 

anaesthesia.     Lancet,  Lond.,  Feb.  26,  1916,  p.  463-64. 

26.  Disciplinary  treatment  of  shell  shock  (Notes  from  German  and 

Austrian  journals)     Brit.  med.  j.,  Dec.  23,  1916,  p.  882. 

27.  Eder,  M.  D.     Psychopathology    of    the    war    neuroses.     Lancet, 

Lond.,  Aug.  12,  1916,  p.  264-68. 

28.  Eder,  M.  D.    War  shock — the  psychoneuroses  in  war;  psychology 

and  treatment.     Lond.,  Heinemann,  1917.     154  p. 

29.  Elliot,  T.  R.     Transient  paraplegia  from  shell  explosions.     Brit. 

med.  j.,  Dec.  12,  1914,  p.  1005. 

30.  Emslie,  Isabel.     War  and  psychiatry.     Edin.  med.  j.  14:  359,  1915. 

31.  Farrar,  Clarence  B.     Problem  of  mental  disease  in  the  Canadian 

army.     Mental  hygiene  1 :  389-91,  July  1917. 

32.  Farrar,  Clarence  B.     War  and  neuroses,  with  some  observations 

of  the  Canadian  expeditionary  force.     Amer.  j.  of  insanity  73: 
693-719,  April  1917. 

33.  Felling,  Anthony.     Loss  of  personality  from  shell  shock.     Lancet, 

Lond.,  July  10,  1915,  p.  63-65. 

34.  Fenwick,  P.  C.  C.     Enterospasm  following  shell  shock.     Practi- 

tioner, Lond.,  98:  391,  April  1917. 


REFERENCES  IN  ENGLISH  71 

35.  Forsyth,  David.     Functional  nerve  disease  and  the  shock  of  battle; 

a  study  of  the  so-called  traumatic  neuroses  arising  in  connection 
wath  the  war.     Lancet,  Lond.,  Dec.  25,  1915,  p.  1399-1403. 

36.  Functional  psychic  disturbances  in  the  light  of  war  (Editorial) 

Med.  rec.  90:  374,  Aug.  26,  1916. 

37.  Garton,  Wilfred.     Shell  shock  and  its  treatment  by  cerebro-spinal 

galvanism.     Brit.  med.  j.,  Oct.  23,  1916,  p.  534-36. 

38.  Glueck,  Bernard.     The  malingerer;  a  clinical  study.     International 

clinics,  V.  3,  series  25,  p.  200-51.     References. 

39.  Goddard,  Henry  Herbert.     Place  of  intelligence  in  modern  warfare. 

U.  S.  nav.  med.  bull.  11:  283-89,  July  1917. 

40.  Harris,  Wilfred.     Nerve  injuries   and   shock.     Oxf.    Univ.   press. 

1915.     127  p.     Pt.  2. 

41.  Harwood,  T.  E.     Preliminary  note  on  the  nature  and  treatment  of 

concussion.     Brit.  med.  j.,  April  15,  1916,  p.  551. 
*42.  Hertz,  Arthur  F.     Classification  of  war  neuroses.     Guy's  hosp. 
gaz.  31 :109,  March  24, 1917. 

43.  Hertz,  Arthur  F.     Functional  nervous  disorders.     (In  his  Medical 

diseases  of  the  war.  Lond.,  Arnold,  1916.  Chapter  1  :l-40  Ref- 
erences.) 

44.  Hertz,  Arthur  F.    Nerves  and  the  war.     Guy's  hosp.  gaz.,  Lond., 

29:  169-73,  April  10,  1915. 

45.  Hertz,  Arthur  F.     Paresis  and  involuntary  movements  following 

concussion  caused  by  a  high  explosive  shell.  Royal  soc.  med.. 
Section  of  neurol.  and  psychiatry.     Proceedings  8 :  83,  June,  1915. 

46.  Hertz,  Arthiu-  F.,  and  Ormond,  Arthur  W.     Treatment  of  "con- 

cussion blindness."     Lancet,  Lond.,  Jan.  1,  1916,  p.  15-17. 

47.  Hoch,  August.     Review  of  Karl  Birnbaum's  "War  neiu-oses  and 

psychoses,"  etc.,  pub.  in  Zeitschrift  fur  die  gesammte  Neurologic 
and  Psychiatric,  Referate  and  Ergebnisse,  11:  321-67,  1915. 
N.  Y.  state  hospital  bull.,  new  series,  8 :  287-91,  1915. 

48.  Hotchkis,  R.  D.     Renfrew  district  asylum  as  a  war  hospital  for 

mental  invahds;  some  contrasts  in  administration,  with  an  analy- 
sis of  cases  admitted  during  the  first  year,  J.  of  ment.  science, 
Lond.,  63:  238-49,  April  1917. 

49.  Houston,  W.  R.    War's  amazing  effect  on  nerves    of    soldiers. 

N.  Y.  Times,  March  25,  1917. 

50.  Rowland,   Goldwin  W.     Neuroses   of  returned  soldiers.     Amer. 

med.,  new  series,  12:  313-19,  May  1917. 

*Name  changed  during  war  to  Hurst. 


72  MENTAL  DISEASES  AND  WAR  NEUROSES 

51.  Hunt,  J.  Ramsay.     Psychoneuroses  of  war.    Med.  annual,  Lond., 

1917,  p.  432. 
Hurst,  Arthur  F.     See  Hertz. 

52.  Hypnotism  in  war  hysteria  (Beriin  letter,  Dec.  14,  1915)     J.  of 

Amer.  med.  assoc.  66:  440-41,  Feb.  5,  1916. 

53.  Hysterical  fimctional  impotency  (Med.  notes  from  the  front)  N.  Y. 

med.  j.  106:  368,  Aug.  25,  1917. 

54.  Insanity  and  the  war  (Editorial)     Lancet,  Lond.,  Sept.  4,  1915,  p. 

553. 

55.  Jelhffe,  Smith  Ely.     War  and  the  nervous  system :  peripheral  nerve 

injuries.    N.  Y.  med.  j.  106:  17-21,  July  7,  1917.     Illus.  Refer- 
ences. 

56.  Jenkins,  H.  E.     Mental  defectives  at  Naval  disciphnary  barracks. 

Port  Royal,  S.  C.     U.  S.  nav.  med.  bull.  9:  211-21,  April  1915. 

57.  Kenyon,  Elmer  L.     The  stammerer  and  army  service.    J.  of  Amer. 

med.  assoc.  69:  664-65,  Aug.  25,  1917. 

58.  King,  Edgar.     Mental  disease  and  defect  in  U.  S.  troops.     Wash. 

Govt,  print.  ofiP.,  1914.     204  p.     Bull  no.  5,  U.  S.  Surg.-gen.  off. 

59.  King,  Edgar.     The  military  delinquent.     Mil.  surg.  37:  574-78, 

Dec.  1915. 

60.  London  asylum  and  hospital  for  mental  diseases.  Stone.     Fifty- 

first  annual  report,  1916      ...     by  R.  H.  Steen. 

61.  Lumsden,  Thomas.    Psychology   of   malingering   and   functional 

neuroses  in  peace.     Lancet,  Lond.,  Nov.  18,  1916,  p.  860-62. 

62.  McDowall,  Colin.     Functional  gastric  disturbances  in  the  soldier. 

J.  of  ment.  science,  Lond.,  63:  76-88,  Jan.  1917. 

63.  McDowell,  R.  W.    Diseases  incident  to  submarine  duty.     U.  S. 

nav.  med.  bull.  11:  49,  Jan.  1917. 

64.  MacMahon,  C.     Shell  shock.     Practitioner,  Lond.,  98:  427,  May 

1917. 

65.  McMullin,  J.  J.  A.     Some  observations  on  the  examination  of 

recruits:  defective  minds.  U.  S.  nav.  med.  bull.  9:  73-74,  Jan. 
1915. 

66.  Marriage,  H.  J.     War  injuries  and  neuroses  of  otologic  interest. 

J.  of  laryngol.,  rhinol.  and  otol.  32:  177,  June  1917. 

67.  Mental  strain  of   internment   (Leading  article)     Lancet,  Lond., 

Dec.  9,  1916,  p.  985. 

68.  Midleton,  W.  J.     Nerves  and  the  war.     Med.  times,  Lond.,  42: 

726-28,  Oct.  10,  1914;  742-43,  Oct.  17,  1914;  758-59,  Oct.  24, 
1914;  776-78,  Oct.  31,  1914;  786-88,  Nov.  7,  1914;  802-04,  Nov. 
14, 1914;  835-36,  Nov.  28,  1914;  862-64,  Dec.  12,  1914.     Illus. 


REFERENCES  IN  ENGLISH  73 

69.  Milligan,  E.  T.  C.    Method  of  treatment  of  shell  shock.     J.  of 

Roy.  army  med.  corps  27:  272-73,  Feb.  1917;  also  in  Brit.  med. 
j.,  July  15,  1916,  p.  73-74. 

70.  Milligan,  William,  and  Westmacott,  F.  H.     Warfare  injuries  and 

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71.  Mott,  Frederick  W.     Effects  of  high  explosives  upon  the  central 

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72.  Mott,  Frederick  W.     Mental  hygiene  and  shell  shock  during  and 

after  the  war  (Chadwick  lecture)  Brit.  med.  j.,  July  14,  1917, 
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73.  Mott,  Frederick  W.     Punctiform  hemorrhages  of  the  brain  in  gas 

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74.  Myers,  Charles  S.     Contributions  to  the  study  of  shell  shock,  1-4. 

Lancet,  Lond.,  Feb.  13,  1915,  p.  317-20;  Jan.  8,  1916,  p.  65-69; 
March  18,  1916,  p.  608-13;  Sept.  9,  1916,  p.  461-67;  also  (except 
1)  in  J.  of  Roy.  army  med.  corps  26:  642-55,  782-97,  May  and 
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75.  Natier,  M.     Hysterical  mutism  caused  by  shell  explosion.     Laryn- 

goscope 25:  539,  Aug.  1915. 

76.  National  committee  for  mental  hygiene — Committee  on  war  work — 

Sub-committee  on  clinical  methods  and  standardization  of  exam- 
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N.  Y.  med.  j.  106:  370,  Aug.  25,  1917. 

77.  Nerves  and  war;  the  Mental  treatment  bill.    Lancet,  Lond.,  May 

1,  1915,  p.  919-20. 

78.  Nervous  symptoms  in  wounded  patients  (Paris  letter,  Nov.  25, 

1915)     J.  of  Amer.  med.  assoc.  65:  2180-81,  Dec.  18,  1915. 

79.  Nervous  system  in  naval  warfare  (Editorial)     Med.  rec.  87:  316, 

Feb.  20,  1915. 

80.  Neurasthenia  and  shell  shock  (Leading  article)      Lancet,  Lond., 

March  18,  1917,  p.  627-28. 

81.  Neymann,   Clarence  A.     Some  experiences  in  the  German  Red 

Cross.     Mental  hygiene  1:  392-96,  July  1917. 

82.  Nicoll,  Maurice.    Dream  psychology.    Lond.,  Hodder,  1917.     p. 

190. 

83.  O'Malley,  John  F.     Functional  aphonia.     Roy.  soc.  med..  Section 

of  laryngol.       Proceedings  7:  116,  1915. 

84.  O'Malley,  John  F.     Warfare  neuroses  of  the  throat  and  ear.     Lan- 

cet, Lond.,  May  27,  1916,  p.  1080-82. 


74  MENTAL  DISEASES  AND   WAR  NEUROSES 

85.  Ormond,  A.  W.     Treatment   of  "concussion  blindness."     J.  of 

Roy.  army  med.  corps  26:  43^9,  Jan.  1916. 

86.  Osier,  WUliam.     Functional  nervous  disorders.     J.  of  Amer.  med. 

assoc.  64:  2001-02,  June  12,  1915. 

87.  Parsons,  J.  Herbert.     Psychology  of  tramnatic  amblyopia  following 

explosion  of  shells.  Roy.  soc.  med..  Section  of  neurol.  and  psy- 
chiatry. Proceedings  7:  55,  April  1915:  also  in  Lancet,  Lond., 
April  3,  1915,  p.  697. 

88.  Paton,  Stewart.     MobiUzing  the  brains  of  the  nation.     Mental 

hygiene,  v.  1,  no.  3,  July  1917. 

89.  Pemberton,  Hugh  S.     Psychology  of  traumatic  amblyopia  follow- 

ing the  explosion  of  shells.     Lancet,  Lond.,  May  8,  1915,  p.  967. 

90.  Penhallow,  D.  Pearce.     Mutism  and  deafness  due  to  emotional 

shock  cured  by  etherization.  Bost.  med.  and  surg.  j.  174:  131, 
Jan.  27,  1916. 

91.  Pierce,   Bedford,   and   Wilson,   Marguerite.     Shell   shock.     Med. 

annual,  Lond.,  1917,  p.  461-66. 

92.  Pierce,  Bedford.     Absence  of  proper  facilities  for  the  treatment  of 

mental  disorders  in  their  early  stages.  Brit.  med.  j.,  Jan.  8,  1916, 
p.  41-44. 

93.  Proctor,  A.  P.     Three  cases  of  concussion  aphasia;  treatment  by 

general  anaesthesia.     Lancet,  Lond.,  Oct.  30,  1915,  p.  977. 

94.  Psychic  disturbances  incident  to  the  war  (Berlin  letter,  March  28, 

1916)     J.  of  Amer.  med.  assoc.  66:  1398,  April  29,  1916. 

95.  Regis,  E.     Psychic  and  nem-opsychic  affections  in  war,  tr.  in  Bost. 

med.  and  surg.  j.  175:  784-92,  Nov.  30,  1916. 

96.  Richards,  T.   W.,  tr.     The  nervous  system  and  naval  warfare. 

U.  S.  nav.  med.  bull.  8:  576-86,  Oct.  1914.  The  original  article 
appeared  anonymously  in  Marine-Rundschau,  v.  21,  no.  9. 

97.  Rows,  R.  G.     Functional  nervous  disorders.     Lond.,  Med.  research 

committee,  1915.     Circulated  privately. 

98.  Rows,  R.  G.     Mental  conditions  following  strain  and  nerve  shock. 

Brit.  med.  j.,  March  25,  1916,  p.  441-43. 

99.  Rudolf,  R.  D.     Paralysis  from  fright.     Canadian  med.  assoc.  j.  6: 

289,  April  1916. 

100.  Russel,  CoUn  Kerr.     Study  of  certain  psychogenetic  conditions 

among  soldiers.     Canadian  med.  assoc.  j.  7:  704-20,  Aug.  1917. 

101.  Ryan,  Edward.     Case  of  shell  shock.     Canadian  practitioner  and 

rev.  41:  507-10,  Dec.  1916. 

102.  Salmon,  Thomas  William.     Care  and  treatment  of  mental  diseases 

and  war  neuroses  (shell  shock)  in  the  British  army.  N.  Y.,  Natl, 
comm.  for  mental  hygiene,  1918. 


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104.  Schier,  A.  R.    Review  and  possibilities  of  mental  tests  in  the  exam- 

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105.  Sheehan,  R.     Exclusion  of  the  mentally  unfit  from  the  military- 

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bull.  10:  646-53,  Oct.  1916. 

107.  Sheehan,  R.     Service  use  of  intelligence  tests.     U.  S.  nav.  med. 

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108.  Smith,  G.  Elliot,  and  Pear,  T.  H.     Shell  shock.    Lond.,  Longmans. 

1917.     135  p. 

109.  Smith,  G.  Elliot.     Shock  and  the  soldier.     Lancet,  Lond.,  April  15, 

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110.  Smith,  Lloyd  L.     Syphilis  as  a  cause  of  mental  disease  in  the  mili- 

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113.  Special  discussion  of  shell  shock  without  visible  signs  of  injury. 

Royal  soc.  med..  Section  of  neurol.  and  psychiatry.  Proceedings 
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114.  Stewart,  Purves,  and  Evans,  Arthur.     Nerve  injuries  and  their 

treatment.  Lond.,  Frowde,  1916.  208  p.  illus.  Chapter  4: 
37-48. 

115.  Thomas,  G.  E.     Second  report  in  the  Schier  test  for  mentality, 

with  special  reference  to  the  point  system.  U.  S.  nav.  med.  bull. 
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116.  Thomas,  G.  E.     Value  of  the  mental  test  and  its  relation  to  the 

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118.  Thomas,  John  Jenks.     Types  of  neurological  cases  seen  at  a  base 

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120.  TUley,  Herbert.    Two  cases  of  functional  aphonia  (one  including 

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imity to  the  patient.  Roy.  soc.  med.,  Section  of  laryngol.  Pro- 
ceedings 8:  115,  June  1915. 

121.  Tombleson,  J.  Bennett.     Series  of  military  cases  treated  by  hyp- 

notic suggestion.     Lancet,  Lond.,  Oct.  21,  1916,  p.  707-09. 

122.  Townsend,  R.  O.     Case  of  malingering  or  true  neurosis;  case  of 

malingering  or  hysteria.     Practitioner,  Lond.,  99:  88,  July  1917. 

123.  Treatment  of  nervous  and  mental  shock  in  soldiers  (London  letter, 

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124.  Trotter,  W.     Instincts  of  the  herd  in  peace  and  war.     Lond.,  Un- 

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APPENDIX  II 

THE   USE   OF   INSTITUTIONS   FOR   THE   INSANE   AS 
MILITARY  HOSPITALS 


APPENDIX  II 

THE  USE  OF  INSTITUTIONS  FOR  THE  INSANE  AS  MILITARY 

HOSPITALS 

IN  January  1915,  when  the  pressure  upon  the  Royal  Army 
Medical  Corps  to  provide  additional  hospital  beds  for 
wounded  soldiers  became  acute,  the  Board  of  Control  was  asked 
by  the  War  Office  to  co-operate  in  an  attempt  to  secure  50,000 
beds.  All  other  government  departments  having  institutions 
under  their  control  were  also  asked  to  assist.  The  Board  of 
Control  formulated  a  plan  whereby  92  county  and  borough  asy- 
lums were  to  be  divided  into  ten  groups  and  one  institution  in  each 
group  vacated  of  its  patients  and  turned  over  to  the  War  Office 
as  a  military  hospital.  It  was  planned  to  provide  in  this  way 
15,000  beds  or  almost  one  third  of  the  total  number  required. 
The  methods  by  which  this  plan  was  put  into  execution  were  so 
thorough  and  expeditious  that  an  account  of  how  it  was  done  may 
be  useful  to  those  who  may  be  confronted  with  a  similar  task  in  this 
country  if  the  fortunes  of  war  should  demand  it.* 

As  soon  as  the  plans  of  the  Board  of  Control  had  been  formu- 
lated a  circular  (Circular  A — Use  of  Asylums  as  Military  Hospitals) 
was  sent  out  to  all  chairmen  and  clerks  of  Visiting  Committees 
and  all  Medical  Superintendents.  A  copy  of  this  circular,  a  circu- 
lar giving  the  observations  of  the  War  Office  on  the  plan  (B-Use  of 
Asylums  as  Military  Hospitals),  and  the  letter  which  accompanied 
them  follows: 

A.    USE  OF  ASYLUMS  AS  MILITARY  HOSPITALS 

Scheme,  prepared  by  the  Board  of  Control,  for  the  general  administration  of  vacated 
asylums,  and  the  details  of  reimbursement  which  the  War  Office  undertakes  to  make  to 
receiving  and  vacated  asylums. 
I.  Charges  arising  from  the  maintenance  and  treatment  of  sick  and  wounded  soldiers  in 
Asylum  Buildings,  which  the  Army  Council  undertakes  to  meet. 

*  Very  interesting  articles  by  Lt.  Col.  D.  G.  Thomson  {Journal  of  Mental  Science,  64: 
109-35,  January  1916)  and  Major  R.  D.  Hotchkis  {Journal  of  Mental  Science,  63:  245-49, 
April  1917)  give  accounts  of  the  measures  taken  in  England  and  Wales  to  convert  county 
asylums  into  war  hospitals  and  particularly  of  the  conversion  of  the  institutions  of  which 
they  were  superintendents,  namely,  the  Norfolk  County  Asylum  and  the  Renfrew  District 
Asylum,  respectively.  In  the  discussion  of  Col.  Thomson's  paper  {loc.  cit.)  other  superin- 
tendents of  institutions  which  had  been  converted  into  war  hospitals  gave  their  expe- 
riences. 

6  81 


82  MENTAL  DISEASES  AND  WAR  NEUROSES 

1.  Vacated  Astlums 

(a)  Charges  in  connection  with  buildings  and  equipment. 

i.  Necessary  adaptations  of  the  buildings  for  hospital  purposes, 
ii.  Maintenance  and  repairs  of  premises. 

iii.  Reinstatement  of  premises  at  end  of  occupation  by  Army  Council, 
iv.  Additional  equipment  found  necessary:  e.  g.,  hospital  requirements,  extra 
beds,  etc. 
Note: — All  extra  equipment  purchased  at  the  expense  of  the  War  Office 
which  remains  in  stock  at  the  conclusion  of  the  war,  is  to  be  regarded  as  the 
property  of  the  War  Office,  but  may,  if  the  asylum  authorities  so  desire,  be 
taken  over  by  them  wholly  or  in  part  at  a  valuation. 

(b)  Charges  in  connection  with  the  maintenance  of  staff  and  of  soldier  patients. 

i.  Salaries  and  wages,  including  fees  to  surgeons  and  other  experts,  and  remun- 
eration of  other  persons  called  in  to  supplement  ordinary  staff. 
ii.  Victualling  on  scales  laid  down  by  Army  Council, 
iii.  Uniform  for  staff  and  clothing  for  patients, 
iv.  Furniture  and  bedding.     (Renewals  and  repairs.) 
V.  Medicines,  surgical  appliances  and  instruments, 
vi.  Fuel,  lighting,  washing  and  other  necessaries, 
vii.  Rates,  taxes  and  insurance. 

viii.  Incidental  expenses,  including  travelling,  burials,  etc. 
i.  Receiving  Asylums 

Charges  in  connection  with  the  maintenance  of  lunatics, 
i.  Additional  weekly  cost  of  maintenance,  if  any. 
ii.  Equipment  and  stores  required  for  additional  numbers  and  extra  cost  of 

maintenance  and  depreciation, 
iii.  Any  necessary  slight  structural  alterations  necessitated  by  increased  num- 
bers, extra  wear  and  tear,  and  reinstatement  of  premises. 
3.  Cost  of  all  Necessary  Travelling  and  Conveyance  of  Lunatics 
n.  General  Arrangements. 

1.  The  War  Office  will  be  solely  responsible  for  the  medical  care  and  treatment  of  the 
soldiers  and  the  management  of  the  hospital. 

2.  The  asylums  will  be  handed  over  as  going  concerns  mth  the  whole  of  their  staff, 
medical,  engineering,  stores,  farms,  etc.,  and  such  part  of  the  nursing  and  attendant  staff 
not  needed  to  accompany  the  patients  to  the  receiving  asylums.  The  portion  of  the  nurs- 
ing staff  retained  at  the  asyliun  should  be  that  portion  best  suited  to  take  up  or  assist  in  the 
care  of  the  sick  and  wounded. 

3.  The  War  Office  will  appoint  the  additional  medical  and  nursing  staff  required  for  the 
hospital.  The  visiting  committee  and  the  medical  superintendent  will  generally,  from 
their  local  knowledge,  be  able  to  suggest  suitable  persons  for  employment  in  addition  to 
those  already  in  War  Office  service. 

4.  Subject  to  the  directions  of  the  committee,  the  medical  superintendent  is  the  head  and 
director  of  the  asylum  administration,  and  in  most  instances,  no  doubt,  he  will  be  appointed 
by  the  War  Office  to  be  the  officer  in  charge  of  the  hospital.  If  so  appointed  he  wiU  con- 
tinue to  exercise  the  general  control  over  the  institution  and  its  staff  and  working,  for  which 
his  experience  specially  qualifies  him.  The  other  medical  officers  of  the  asylum  will  ordi- 
narily be  quaUfied  and  willing  to  become  part  of  the  medical  staff  of  the  hospital,  and  to 
share  the  duties  with  the  additional  professional  staff  sent  by  the  War  Office. 

5.  The  whole  of  the  asylum  staff  is  in  the  employment  of  the  visiting  committee  by  whom 
they  are  appointed  and  by  whom  they  can  be  dismissed.     They  are  in  established  pension- 


INSTITUTIONS  AS  MILITARY  HOSPITALS  83 

able  service,  and  it  is  necessary  that  their  asylum  service  should  be  unbroken,  except  for 
misconduct.  If  in  any  instance  it  is  expedient  that  the  head  of  the  hospital  should  be  an 
officer  other  than  the  medical  superintendent,  it  is  desirable  that  he  should  delegate  the 
lay  administration  of  the  institution  to  the  committee  which,  from  experience  and  local 
knowledge,  is  obviously  the  authority  best  qualified  to  carry  it  on.  The  medical  chief  will 
thus  be  relieved  from  many  laborious  administrative  tasks.  The  delegation  may  be  subject 
to  such  conditions  as  are  thought  reasonable. 

6.  The  War  Office  have  decided  that  military  rank  shall  be  conferred  on  the  members  of 
the  medical  staff.  If  an  officer  of  higher  rank  than  the  medical  superintendent  is  sent  to  the 
hospital,  it  is  desirable  that  the  general  administration  of  the  institution  should  be  delegated 
to  the  medical  superintendent,  or  at  any  rate  in  practice  left  in  his  hands.  As  regards  the 
male  attendants,  it  may  be  thought  necessary,  as  has  been  done  at  the  state  institution  at 
Moss  Side,  to  incorporate  them  in  the  Red  Cross  organization. 

7.  The  committee  will  continue  to  make  contracts  for  supplies,  and  otherwise  carry  on 
the  business  side  of  the  administration,  will  open  a  fresh  banking  account  from  the  date 
when  the  War  Office  are  in  possession,  and  the  clerk  will  each  mouth  present  to  the  War 
Office  an  account,  certified  as  the  War  Office  may  require,  of  the  expenditure  incurred. 
These  accounts  will  be  audited  as  heretofore  by  the  asylum  auditors  with  any  additional 
precautions  which  the  War  Office  may  require.  They  should  be  transmitted  to  the  War 
Office  through  the  Board  of  Control  who,  after  such  enquiry — if  any — as  they  think  neces 
sary,  will  append  their  certificate  that  the  claim  is  a  proper  one  to  be  made  on  the  Wa 
Office. 

The  committee  will  be  informed  by  the  War  Office  what  stores,  etc.,  can  be  s 
that  department,  and  what  must  be  contracted  for  locally. 

The  necessary  funds  to  meet  expenditure  on  structural  alterations,  additional  e 
expenses  on  travelling  and  conveyance,  etc.,  will  be  advanced  by  the  War  Office  as  soon  as  a 
decision  is  reached  that  an  asylum  is  to  be  vacated. 

Claims  for  such  advances  should  be  transmitted  through  the  Board  of  Control. 

B.    USE  OF  ASYLUMS  AS  MILITARY  HOSPITALS 

Observations  by  the  War  Office  supplementary  to  their  general  confirmation  of  the  scheme 
prepared  by  the  Board  of  Control: 
1.  Vacated  Astlums 

(a)  Charges  in  connection  with  buildings  and  equipment: 

ii.  Maintenance  and  repairs  of  premises. 

In  case  of  considerable  repairs  constituting  permanent  structural  im- 
provements, the  Board  of  Control  will  no  doubt  be  prepared  to  advise  to  what 
extent  credit  can  be  given  to  the  War  Department  for  these  in  the  final  settle- 
ment. 

iii.  Reinstatement  of  premises  at  end  of  occupation. 

It  is  presumed  that  a  complete  inventory  will  be  taken  before  occupation, 
iv.  Additional  equipment. 

It  is  presumed  that  complete  accounts  will  be  kept  of  equipment  furnished 
by,  or  purchased  at  the  expense  of,  the  War  Department. 

(b)  Charges  in  connection  with  the  maintenance  of  staff  and  of  soldier  patients: 

i.  Salaries  and  wages. 

It  is  presumed  that  the  visiting  committee  mil  actually  pay  (at  War  Depart- 
ment expense)  the  present  salaries  of  the  retained  asylum  staff,  and  any  persons 
temporarily  engaged,  and  that  the  War  Department  will  pay  direct  its  own 
officials.     This  is  merely  a  matter  of  machinery,  and  will  be  pursued  in  the 


84  MENTAL  DISEASES  AND  WAR  NEUROSES 

communication  referred  to  in  paragraph  7  below.     The  rates  to  be  paid  for 
any  persons  temporarily  engaged  will  be  settled  by  the  War  (Mice. 

ii.  Victualling. 

Presumably  consumable  stores  taken  over  wiU  be  valued  and  the  cost 
credited  to  the  asylum  authorities. 

It  is  presumed  that  appropriate  accounts  of  consumables,  etc.,  whether  sup- 
plied by  the  War  Department  or  purchased  on  their  behalf  by  the  asylum 
authorities  will  be  kept,  and  that  these  accounts  will  be  available  for  inspection, 
if  desired. 

Medicines  and  medical  and  surgical  equipment  when  not  taken  over  with  the 
asylum  will  be  provided  by  the  War  Office  or  under  arrangements  approved  by 
them. 

Receipts  Generally. 

It  is  presumed  that  the  produce  of  asylum  farms  will  be  available  for  use, 
and  that  the  War  Department  will  be  allowed  credit  for  produce  sold.  Also  the 
War  Department  will  receive  credit  for  the  grants  received  by  the  asylum 
authorities  in  respect  of  any  harmless  patients  retained  for  work  on  farms  or 
grounds,  since  they  wiU  be  maintained  out  of  general  maintenance  of  which  the 
War  Department  is  bearing  the  cost,  and  generally  that  any  receipts  arising  out 
of  the  ordinary  working  of  those  institutions  while  they  are  in  use  by  the  War 
Department  will  be  taken  in  reduction  of  the  working  expenses  chargeable 
against  the  War  Office. 
2.  Receiving  Asylums. 

(i)  Additional  weekly  cost  of  maintenance,  if  any. 

It  is  presumed  that  the  authorities  of  the  vacating  asylum  will  continue  to 
draw  their  grants  in  respect  of  patients  transferred  and  of  patients  who  would 
be  sent  there  but  for  War  Department  occupation,  that  the  vacating  asylum  will 
pay  to  the  receiving  asylum  the  weekly  cost  of  maintenance  therein,  and  that 
the  War  Department  will  refund  to  the  vacating  asylum  the  excess  in  cases 
where  their  grant  is  less  than  the  weekly  cost  in  the  receiving  asylum. 

In  cases  in  which  the  weekly  cost  is  less,  this  department  would  not  propose 
that  the  saving  should  be  taken  into  account  unless  the  saving  is  of  material 
amount,  in  which  case  the  charge  under  (ii)  below  should  apparently  be  abated. 
(ii  and  iii)  Equipment  and  stores  required. 

It  is  presumed  that  an  account  will  be  kept  of  the  additional  equipment,  and 
that  such  equipment  may  be  taken  over  on  evacuation  at  a  valuation  as  in  case 
of  vacating  asylum.  This  department  will  readily  fall  in  with  your  views  as  to 
the  manner  of  payment  for  these  services. 

General  Arrangements. 

(2)  If  a  portion  of  the  staff  is  transferred  to  a  receiving  asylum,  it  is  presumed  that 

the  salaries  will  not  be  a  charge  for  the  War  Department. 

(3)  After  "nursing"  in  line  1,  add  "or  other." 

(4)  After  "War  Office"  in  line  3,  add  "under  the  general  officer  commanding-in- 

chief  of  the  command  concerned." 

(6)  Delete  the  first  three  lines  and  substitute,  "If  the  War  Office  in  any  given  case 
should  appoint  an  officer  of  senior  rank  to  the  hospital  it  is  desirable  that  the 
general.     .     .     ." 

(7)  It  is  suggested  that  when  an  asylum  is  taken  over,  an  advance  be  made  by  the 

War  Department  on  the  recommendation  of  the  Board  of  Control  on  the  basis 
of  a  month's  (or  quarter's)  estimated  expenditure  (plus  initial  costs  in  the  first 


INSTITUTIONS  AS  MILITARY  HOSPITALS  85 

instance)  and  that  periodical  accounts  should  be  rendered  to  the  War  Depart- 
ment through  the  Board  of  Control  as  suggested.  A  further  communication 
will,  however,  be  addressed  to  the  Board  of  Control  as  regards  the  procedure 
in  rendering  accounts,  but  this  department  will  be  prepared  to  make  advances 
as  soon  as  desired. 

"The  Board  of  Control, 
66  Victoria  Street,  S.  W., 

10th  March,  1915. 
Sir: 

I  am  directed  by  the  Board  of  Control  to  transmit  to  you  a  copy,  "A,"  of  the  scheme 
prepared  by  the  board  for  the  general  administration  of  the  vacated  asylums,  and  the 
details  of  reimbursement  which  the  board  suggested  the  War  Office  should  undertake  to 
make  to  receiving  and  vacated  asylums. 

The  board,  on  the  6th  instant,  received  from  the  War  Office  a  letter  expressing  the  general 
concurrence  of  the  Army  Council  with  the  detailed  financial  arrangements  mentioned 
above.  A  statement  was  enclosed  setting  forth  some  minor  points  on  which  it  appeared  to 
the  Army  Council  desirable  to  arrive  at  a  clearer  understanding,  and  on  which  they  thought 
the  statement  might  perhaps  with  some  advantage  be  modified.  It  was  also  added  that 
the  actual  details  regarding  staff  requirements,  technical  equipments,  and  the  like,  mil  be 
settled  by  arrangement  i\-ith  the  War  Office  in  each  particular  case. 

A  copy  of  the  War  Office  statement — marked  "B" — is  herewith  enclosed.  It  is  to  be 
observed  that  on  page  1,  under  "Receipts  Generally"  the  ^^ew  is  entertained  that  the 
accounts  of  the  farm  at  the  vacated  asylum  would  be  included  in  those  of  the  War  Office. 
The  board,  however,  contemplated  that  the  asylum  farms  would  be  managed  by  the  visit- 
ing committees;  that  the  accounts  would  be  kept  separately  from  those  relating  to  sick  and 
wounded  soldiers;  and  that  supplies  of  vegetables  and  other  produce  to  the  hospital  would 
be  charged  for  at  reasonable  prices,  say  current  market  rates,  and  would  be  debited  to  the 
War  Office  account.  Inasmuch  as  many  of  the  farms  are  big  enterprises  with  considerable 
stock  (both  live  and  dead)  the  board  think  that  this  course  would  be  preferable  and  gener- 
ally more  equitable  than  the  alternative  of  including  the  entire  farm  accounts  in  the  ac- 
coimts  for  soldiers.  The  War  Office  have,  however,  stated  that  either  of  these  alternative 
methods  would  be  agreeable  to  them;  it  is  a  point  that  easily  lends  itself  to  adjustment  be- 
tween now  and  the  date  when  the  asylums  are  handed  over. 

The  board  agree  that  it  would  be  right  that  expenditure  in  respect  of  harmless  lunatic 
patients  retained  at  the  hospital  should  be  charged  in  the  War  Office  account  and  that 
credit  should  be  taken  therein  of  all  sums  received  from  guardians  in  respect  of  their 
maintenance.  The  effect  of  this  arrangement  will  be  that  no  charge  will  fall  on  the  War 
Office. 

Under  No.  6,  on  page  2,  the  board  understand  that  the  War  Office  are  prepared  to  grant 
military  rank  to  certain  members  of  the  medical  staff,  and  that  the  omission  of  the  words 
"The  War  Office  .  .  .  Medical  Staff"  in  the  first  lines  was  not  intended  to  affect  the 
decision. 

With  regard  to  the  second  paragraph  on  page  2  commencing  "In  cases  in  which  the 
weekly  cost  is  less  ..."  the  board,  as  some  of  their  members  have  explained  when 
this  question  has  come  up  at  conferences,  are  of  the  opinion  that  the  Lunacy  Act  appears 
to  require  that  not  more  than  the  actual  cost  of  maintenance  be  claimed  from  the  guardians, 
and  if  this  principle  is  adhered  to  the  question  of  an  abatement  to  the  War  Office — as 
referred  to  in  this  paragraph — will  not  arise. 

The  board  have  given  carefij  consideration  to  all  the  points  set  out  in  the  War  Office 
statement.     They  are  of  the  opinion  that  none  of  them  conflicts  with  any  of  those  in  the 


86  MENTAL  DISEASES  AND   WAR  NEUROSES 

board's  scheme.  The  latter  was  based  on  the  conditions  upon  which  the  various  asylum 
authorities  so  w-illingly  promised  their  assistance,  and  the  board  have  confidence  that  they 
will  agree  that  the  interests  of  the  ratepayers  and  the  position  of  the  visiting  committees 
have  been  amply  and  properly  safeguarded. 

In  gladly  accepting  the  offer  of  the  nine  asylums  to  be  vacated,  the  War  Office  have  stated 
how  much  they  appreciate,  not  only  the  willingness  of  the  authorities  and  staff  of  those  in- 
stitutions to  place  them  at  their  disposal,  but  also  the  hearty  co-operation  of  the  authorities 
and  staff  of  all  the  receiving  asylums,  without  which  they  realize  that  the  scheme  would  not 
have  been  practicable. 

I  am. 
Sir, 
Your  obedient  Servant, 

(Signed)    O.    E.    Dickinson, 
Secretary." 

The  first  employment  of  this  plan  made  about  12,000  beds 
available.  Since  then  additional  institutions  under  the  Board  of 
Control,  and  under  the  boards  exercising  similar  functions  in 
Scotland  and  Ireland,  have  been  taken  over  for  military  purposes. 
On  July  1, 1917,  twenty-one  such  institutions  with  a  total  capacity 
for  military  patients  of  27,158,  had  been  made  available  for  the 
use  of  the  War  Office.  A  list  of  these  institutions  showing  their 
capacity  as  civil  institutions  and  as  military  hospitals  and  indicat- 
ing those  which  have  been  used  for  mental  and  nervous  cases 
is  given  on  the  following  page. 

In  all  cases,  even  where  the  military  hospital  was  to  be  used  for 
insane  soldiers,  the  name  was  changed  "to  escape  the  asylum 
tradition."  This  is  a  pathetic  reminder  of  the  stigma  which  still 
clings  to  mental  diseases  and  institutions  for  their  care  in  England. 
The  old  names  of  these  institutions  with  their  "asylum  traditions" 
are  still  good  enough  for  the  wives,  mothers  and  daughters  of 
soldiers.  It  is  earnestly  hoped  by  the  men  in  England  who  are 
striving  to  change  this  popular  attitude  toward  mental  illness  that, 
when  the  war  is  over,  the  new  names  will  be  retained  and  the 
word  "asylum"  will  be  permanently  replaced  by  the  word  "hos- 
pital." 

The  transfer  of  upwards  of  15,000  insane  patients  was  success- 
fully and  safely  made,  although  not  without  distressing  incidents. 
Col.  Thomson  said  that  in  his  institution  he  was  surprised  to  see 
the  attachment  which  old  patients  felt  for  the  place  which  had 
been  their  home  for  so  many  years — in  some  cases  from  childhood. 
The  other  institutions  were  able  to  absorb  these  great  additions 
to  their  population  but  only  with  considerable  inconvenience  and 


INSTITUTIONS  AS  MILITARY  HOSPITALS 


87 


County  and  Borough  Asylums  which  have  been  Vacated  of  their 
Patients  and  Converted  into  Military  Hospitals, 
July  1,1917 


Capacity 

Former  name 

Present  name 
(as  a  military  hospital) 

(as  a  civil  institution) 

Former 

Present 

England: 

Newcastle-on-Tyne  City  Asy- 

The     Northumberland      War 

lum,   Gosforth,   Newcastle- 

Hospital. 

884 

1,179 

on-Tyne. 

West  Riding  of  Yorks  Asylum, 

The  Wharneliffe  War  Hospital 

1,699 

2,265 

Wadsley  (New  Sheffield). 

Lancashire    County    Asylum, 

*The  Lord  Derby  War  Hospital 

2,248 

2,997    (1) 

Winwick,  Warrington. 

Birmingham     City     Asylum, 

The    1st    Birmingham    War' 

Rubery  Hill,  Birmingham. 

Hospital. 

1,397 

2,363 

Birmingham     City     Asylum, 

The    2d     Birmingham     War 

Hollymoor,  Birmingham. 

Hospital. 

Norfolk       County       Asylum, 

The  Norfolk  War  Hospital. 

1,045 

1,393 

Thorpe,  Norwich. 

West    Sussex    Asylum,    Chi- 

The Graylingwell  War  Hospital. 

729 

972 

chester. 

Bristol  County  and  City  Asy- 

The Beaufort  War  Hospital. 

937 

1,249 

lum,  Fishponds,  Bristol. 

London  County  Asylum,  Hor- 

The  Horton  (County  of  London) 

2,174 

2.899 

ton,  Epsom. 

War  Hospital. 

Middlesex     County    Asylum, 

tThe  County  of  Middlesex  War 

Napsbury,  St.  Albans. 

Hospital. 

1,800 

1,520    (2) 

Middlesex    County    Asylum, 

*The  Springfield  War  Hospital. 

250 

278 

near  Tooting,  London,  S.W. 

(block    for    defective    chil- 
dren). 
Northampton  County  Asylum, 

Northamptonshire  War  Hospi- 

997 

1,329 

Berrywood,  Northampton. 

tal. 

The  Maudsley  Hospital,  Den- 

tPart of  the  4th  London  General 

mark  Hill,  London,  S.E. 

Military  Hospital. 

(3) 

200 

Lancashire    County    Asylum, 

Whalley. 
Hampshire    County    Asylum, 

Queen  Mary  Military  Hospital. 

(4) 

3,000 

Park  Prewett  War  Hospital. 

(4) 

1,000 

Park  Prewett. 

Moss   Side   State   Institution, 

*Moss  Side  Red  Cross  Military 

Maghull  (near  Liverpool). 

Hospital. 

(5) 

345 

London  (Manor)  County  Asy- 

Manor (County  of  London)  War 

lum,  Epsom. 

Hospital. 

1,085 

1,447 

Wales: 

Cardiff   City   Asylum,   Whit- 

The Welsh  Metropolitan  War 

729 

972 

church,  Cardifi. 

Hospital. 

Scotland: 

Renfrew      District      Asylum, 

Paisley. 
Perth  District  Asylum. 

fThe  Dykebar  War  Hospital. 

850 

tThe  Murthley  War  Hospital. 

(?) 

400 

Ireland: 

The  Belfast  District  Asylum. 

fThe  Belfast  War  Hospital. 

(?) 

500 

Belfast. 

*  For  nervous  cases.  f  For  mental  cases.         t  For  mental  and  nervous  cases. 

(1)  1,000  beds  for  mental  cases.  (2)  350  beds  for  mental  cases,  (3)  New  psycho- 
pathic hospital;  never  occupied.  (4)  New  institution  for  the  insane;  never  occupied. 
(6)  New  institution  for  mentally  defective  delinquents;  never  occupied. 


88  MENTAL  DISEASES  AND  WAR  NEUROSES 

some  hardships.  A  few  patients  were  taken  home  by  their 
friends.  Partly  as  a  result  of  the  inability  of  the  overcrowded 
institutions  to  take  new  cases  except  in  emergencies  and  partly  as 
a  result  of  the  reluctance  of  relatives  to  send  patients  to  distant 
institutions,  the  admission  rate  from  the  civil  population  of 
England,  Scotland  and  Ireland  has  shown  a  considerable  reduc- 
tion. In  the  United  States  we  have  ample  evidence  of  the  effect 
upon  the  admission  rate  of  the  standard  of  care  provided  by 
public  institutions  and  have  seen  how  easy  it  is,  in  states  which 
shirk  their  responsibilities  in  this  matter,  to  force  the  insane  back 
upon  their  homes.  In  many  of  the  hospitals  from  twenty  to 
eighty  of  the  quiet  male  patients  able  to  work  remained — usually 
in  detached  villas.  Such  patients  are  happy  and  carry  on  the 
work  with  which  they  are  familiar  in  the  novel  surroundings  of  a 
military  hospital. 

The  total  cost  of  turning  over  these  institutions  was  not  as- 
certained.    In  the  case  of  the  Norfolk  Asylum  it  was  $90,000.00. 

The  capacity  of  the  institutions  was  almost  invariably  increased, 
the  average  ratio  being  4 :3.  This  is  due  to  the  fact  that  most  of 
the  day  rooms  could  be  used  as  wards  and  dormitories,  so  large  a 
proportion  of  medical  and  surgical  patients  being  bed  patients. 

A  revolution  came  into  the  lives  of  the  personnel  of  these  in- 
stitutions. The  medical  superintendents,  with  one  exception, 
were  left  in  charge  of  their  institutions,  receiving  commissions  as 
lieutenant  colonel  or  major  (temporary)  in  the  Royal  Army 
Medical  Corps.  Some  of  the  junior  physicians  who  were  com- 
missioned in  the  Army  were  retained  at  their  hospitals.  A  way 
of  "doing  their  bit"  was  provided  for  the  male  attendants  through 
their  enlistment  in  the  Royal  Army  Medical  Corps  under  a  special 
arrangement.  This  solved  for  the  superintendents  the  perplexing 
problem  of  keeping  their  employees.  Responsible  employees  be- 
came non-commissioned  officers,  and  some  helpers,  ineligible  for 
military  service,  were  retained  as  civilian  employees.  The 
female  attendants  became  probationers  in  the  nursing  corps.  In 
most  cases  the  change  was  satisfactory.  Many  of  the  younger 
women  have  been  attracted  by  the  work  of  general  nursing  and 
will  probably  complete  their  training  after  the  war.  All  will  be 
better  attendants  for  the  training  they  have  received.-  In  the 
case  of  a  few  older  female  attendants  who  had  not  had  the  ad- 


INSTITUTIONS  AS  MILITARY  HOSPITALS  89 

vantage  of  a  regular  nurses'  training  but  had  filled  places  of  re- 
sponsibility, some  friction  developed.  The  general  spirit,  how- 
ever, has  been  that  of  hearty  good-will  in  the  new  work.  This 
has  been  due  in  large  measure  to  the  great  part  which  the  war  has 
come  to  play  in  the  lives  of  Englishmen  and  Englishwomen  and 
the  deep  feeling  of  obligation  to  serve  their  country  which  in- 
spires people  in  all  stations  of  life.  It  is  very  doubtful  if  such  an 
enormous  and  difficult  task  as  the  conversion  of  these  institutions 
to  another  purpose  could  have  been  successfully  accomplished 
without  patriotic  submergence  of  self-interest  by  officers  and 
employees. 

In  the  institutions  which  are  used  as  military  hospitals  for 
mental  cases  (see  list,  p.  87)  the  changes  made  were  less  radical. 
The  War  Office  agreed  to  pay  each  member  of  the  staff  his  normal 
salary  except  in  the  few  instances  in  which  this  was  less  than  the 
compensation  of  the  new  rank,  in  which  case  the  latter  amount 
was  paid.  The  female  attendants  presented  a  difficult  problem 
in  these  hospitals,  as  female  attendants  are  not  yet  generally 
employed  in  male  wards  in  English  hospitals  for  mental  diseases. 
In  one  hospital  (Dykebar)  it  was  found  possible  to  staff  several 
wards  with  female  nurses  although  a  male  orderly  is  on  duty  in 
each.  Bed  cases  are  cared  for  in  this  hospital  by  female  nurses. 
A  detached  villa  for  convalescent  patients  is  entirely  in  charge  of 
female  nurses.  Another  villa  in  this  hospital  was  entirely  staffed 
with  female  nurses  but  the  type  of  patients  was  not  just  suitable 
and  further  complications  arose  from  the  fact  that  the  charge 
nurse  married  a  patient  upon  his  discharge  and  this  interfered 
with  conditions  apparently  necessary  for  good  discipline.  Other 
wards  in  the  hospital  have  female  nurses  and  they  are  assigned 
to  the  distribution  of  food.  At  night  the  whole  insliitution  is 
under  an  assistant  matron  who  has  three  female  assistants,  a 
sergeant  and  ten  male  orderlies.  One  outcome  of  the  conversion 
of  the  institutions  seems  likely  to  be  the  employment  of  female 
nurses  in  men's  wards  in  civil  institutions  in  England.  No  one 
who  has  seen  the  success  with  which  this  is  done  in  the  United 
States  and  its  rapid  extension  as  a  result  of  its  efficiency  and  the 
increasing  difficulty  of  securing  good  male  attendants  will  regret 
it. 

The  impression  one  gets  in  visiting  the  military  hospitals  which 


90  MENTAL  DISEASES  AND  WAR  NEUROSES 

have  been  created  out  of  civil  institutions  for  the  insane  is  that  an 
enormously  diflBcult  task  has  been  accomplished  in  a  wonderfully 
efficient  way.  Great  credit  for  this  is  due  to  the  Board  of  Control 
for  the  thoughtful  planning  of  the  transfer  in  advance,  but  its 
success  is  due  also  to  the  remarkable  unanimity  with  which  visiting 
committees,  medical  superintendents  and  employees  co-operated 
in  removing  obstacles  and  subordinating  all  other  considerations  to 
the  successful  solution  of  the  entirely  unprecedented  problem 
before  them.  Most  of  the  institutions  are  of  the  cottage  type 
with  many  small  detached  buildings.  They  have  proved  exceed- 
ingly desirable  general  hospitals  and  it  is  doubtful  whether  any 
other  institutions  in  England  would  have  provided  such  excellent 
facilities  for  ill  and  wounded  soldiers.  Nevertheless  one's  thoughts 
turn  to  the  helpless  insane,  never  too  well  provided  for,  who  were 
turned  out  of  their  hospitals  and  whose  comfort  as  well  as  chances 
for  recovery  must  have  been  seriously  impaired  by  the  change. 
The  necessity  was  so  great  that  these  considerations  could  not  be 
taken  into  account.  If  similar  pressure  comes  to  the  United 
States  and  the  interests  of  the  insane  or  any  other  helpless  group 
must  be  subordinated  to  the  great  object  of  winning  the  war,  we 
shall  have  no  choice,  but  we  cannot  help  feeling  that  the  task  of 
vacating  half  the  beds  in  the  state  hospitals  of  a  state  like  New 
York  would  be  undertaken  with  a  heavy  heart  by  those  who  know 
the  needs  of  the  insane,  and  who  realize  how  little  they  share, 
even  in  time  of  peace,  in  the  provisions  which  mitigate  the  sufiFer- 
ings  of  other  ill  persons. 


APPENDIX  III 

SPECIAL   MILITARY  HOSPITALS  FOR  MENTAL   DIS- 
EASES AND  WAR  NEUROSES  ("SHELL  SHOCK") 
IN  GREAT  BRITAIN  AND  IRELAND 

1.  DIRECTORY 

2.  DESCRIPTIONS  OF  INSTITUTIONS  VISITED 


APPENDIX  III 

SPECIAL  MILITARY  HOSPITALS  FOR  MENTAL  DISEASES 

AND  WAR  NEUROSES  ("SHELL  SHOCK")  IN 

GREAT  BRITAIN  AND  IRELAND 

1.  DIRECTORY 
The  hospitals  in  the  following  list  and  descriptions  are  all  special 
hospitals  for  the  treatment  of  mental  diseases  and  war  neuroses.  Neuro- 
logical departments  in  general  hospitals,  as  those  in  the  Royal  Victoria 
Hospital,  Edinburgh,  and  the  territorial  hospitals  in  England,  Scotland 
and  Wales,  are  not  included.  The  Royal  Victoria  Hospital,  Netley, 
is  included  on  account  of  the  fact  that  the  department  is  a  clearing  hos- 
pital. 

ENGLAND 

Present  name:    County  of  Middlesex  War  Hospital 

Former  name:     Middlesex  County  Asylum 

Location:    Napsbury  (near  St.  Albans) 

Name  deft,  for  ment.  or  nerv.:     No  special  name 

Classes  of  cases  received:     Mental  diseases  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  deft.:    Lt.  Col.  (T.)  L.  Rolles- 

ton 
Cafodty: 

Mental  disease 350 

War  neuroses 

Total 350 

Present  name:    The  First  Home  of  Recovery  (Branch  of  Maida 

Vale  Hospital  for  Nervous  Diseases) 
Former  name:     "Highfields"  (a  girls'  school) 
Location:     Golder's  Green,  London 
Name  deft,  for  ment.  or  nerv.:     Whole  hospital  utiHzed 
Classes  of  cases  received:     War  neuroses  (pensioners  only) 
Officer  in  charge  of  ment.  or  nerv.  deft.:    Capt.  (T.)  —  Scott 
Cafacity: 

Mental  disease 

War  neuroses 150 

Total 150 

93 


94  MENTAL  DISEASES  AND  WAR  NEUROSES 

Present  name:     Fourth  London  General  Hospital 

Former  name:    Kings  College  Hospital  and  Maudsley  Hospital 

Location:     Denmark  HiU,  London 

Name  depts.fcrr  meni.  or  nerv.:  "Maudsley  Hospital"    \  clearing 

"Maudsley  extension"  J  hospital 

Classes  of  cases  received:     War  neuroses  (officers  included) 

Officer  in  charge  of  ment.  or  nerv.  deft.:    Major  (T.)  F.  W.  Mott, 
R.A.M.C. 

CaTpadty: 

Mental  disease 27 

War  neuroses 447 


* 


Total 474 

Present  name:    Granville  Canadian  Special  Hospitalf 

Former  name:     Granville  Hotel 

Location:     Ramsgate 

Name  dept.  for  ment.  or  nerv.:     "Medical  Department" 

Classes  of  cases  received:     War  neuroses  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  Colin  Russell, 

C.A.M.C. 
Capacity: 

Mental  disease 

War  neuroses 440 

Total 440 

Present  name:     Letchmere  House 

Former  name:     A  private  institution 

Location:     Ham  Common,  London 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utiUzed 

Classes  of  cases  received:     Mental  diseases  (officers  only) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  N.  H. 
Ohver,  R.A.M.C. 

Capacity: 

Mental  disease 50 

War  neuroses 

Total 50 

*200  in  Maudsley  Hospital. 

■fTo  be  abandoned  and  patients  sent  directly  to  Canada. 


SPECIAL  MILITARY  HOSPITALS  95 

Present  name:     Lord  Derby  War  Hospital 

Former  name:     Lancashire  County  Asylum 

Location:     Warrington  (near  Liverpool) 

Name  deft,  for  ment.  or  nerv.:     No  special  name 

Classes  of  cases  received:     Mental  diseases  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Lt.  Col.  (T.)  Alexander 

Simpson,  R.A.M.C. 
Capacity: 

Mental  disease 1,000 

War  neuroses 

Total 1.000 

Present  name:    Red  Cross  Military  Hospital 

Former  name:     Moss  Side  State  Institution 

Location:     Maghull  (near  Liverpool) 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 

Classes  of  cases  received:     War  neuroses  (Annex  for  31  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  R.  G.  Rows, 

R.A.M.C. 
Capacity: 

Mental  disease 

War  neuroses 377 

Total 377* 

Present  name:    Royal  Victoria  Hospital 

Former  name:     Same 

Location:    Netley 

Name  dept.  for  ment.  or  nerv.:    "D  Block"  for  mental  diseases; 

"Neurological  Wards"  for  war  neuroses 
Classes  of  cases  received:     Mental  diseases  and  war  neuroses 

(including  officers) 
Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  C.  Stanford 

Ross,  R.A.M.C.  for  "D  Block"  and  Major  (T.)  A.,W. 

Hurst,  R.A.M.C.  for  "Neurological  Wards." 
Capacity: 

Mental  disease 128 

War  neuroses 113 

Total 241 

*Includiiig  31  beds  for  officers  in  annex. 


96  MENTAL  DISEASES  AND  WAR  NEUROSES 

Present  name:     Special  Hospital  for  Officers 

Former  name:     A  private  home 

Location:     10-11  Palace  Green,  London 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 

Classes  of  cases  received:     Mental  diseases  and  war  neuroses 

(officers  only) 
Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  J.  C.  Wood, 

R.A.M.C. 
Capacity: 

Mental  disease 10 

War  neuroses 73 

Total 83 

Present  name:    Springfield  War  Hospital 

Former  name:     Department  of  Middlesex  County  Asylum 

Location:     Upper  Tooting,  London 

Name  dept.  for  ment.  or  nerv.:     Springfield  War  Hospital 

Classes  of  cases  received:     War  neuroses  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  Reginald 

Worth,  R.A.M.C. 
Capacity: 

Mental  disease • 

War  neuroses 255 

Total 255 

SCOTLAND 

Present  name:     Craiglockhart  War  Hospital 
Former  name:     "Edinburgh  Hydropathic"  (a  private  institu- 
tion) 
Location:    Slateford  (near  Edinburgh) 
Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 
Classes  of  cases  received:     War  neuroses  (officers  only) 
Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  W.H.  Bryce, 

R.A.M.C. 
Capacity: 

Mental  disease 

War  neuroses 174 

Total 174 


SPECIAL  MILITARY  HOSPITALS  97 

Present  name:     Dykebar  War  Hospital 

Former  name:    Renfrew  District  Asylum 

Location:     Paisley 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 

Classes  of  cases  received:    Mental  diseases  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  R.  D. 
Hotchkis,   R.A.M.C. 

Capacity: 

Mental  disease 500 

War  neuroses 

Total 500 

Present  name:    Dykebar  War  Hospital  Annex 

Former  name 

Location:     Paisley 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 

Classes  of  cases  received:     Mental  diseases  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:     Major  (T.)  R.  D. 
Hotchkis 

Capacity: 

Mental  disease 350 

War  neuroses 

Total   350 

Present  name:    Miuthley  War  Hospital 

Former  name:    Perth  District  Asylum 

Location:    Perth 

Name  dept.  for  ment.  or  nerv.:     Whole  hospital  utilized 

Classes  of  cases  received:     Mental  diseases  (no  officers) 

Officer  in  charge  of  ment.  or  nerv.  dept.:    Major  (T.)  Lewis  Bruce 

Capacity: 

Mental  disease 350 

War  neuroses 

Total 350 


98  MENTAL  DISEASES  AND  WAR  NEUROSES 

IBEIiAJKD 

Present  name:    Military  Hospital 

Former  name:    Belfast  County  Asylum 

Location:     Belfast 

Name  deft,  for  ment.  or  nerv.:    * 

Classes  of  cases  received:    Mental  diseases  and  war  neuroses 

Officer  in  charge  of  ment.  or  nerv.  dept.:    * 

Capacity: 

Mental  disease 500 

War  neuroses * 

Total   * 

2.  DESCRIPTIONS  OF  HOSPITALS  VISITED 

Descriptions  of  special  hospitals  with  detailed  accounts  of  their  work 
cannot  be  given  in  the  copies  of  this  report  which  are  to  be  generally 
distributed,  as  these  hospitals  were  visited,  with  the  official  consent  of 
the  British  War  Office,  for  the  sole  purpose  of  making  observations  likely 
to  be  useful  to  American  miUtary  hospitals  of  similar  character. 

•Unascertained. 


APPENDIX  rV 

FACILITIES  NEEDED  FOR  EFFICIENT  TREATMENT 

OF  MENTAL  DISEASES  IN  A  MODERN  PUBLIC 

INSTITUTION 


APPENDIX  IV 

FACILITIES  NEEDED  FOR  EFFICIENT  TREATMENT  OF  MEN- 
TAL DISEASES  IN  A  MODERN  PUBLIC  INSTITUTION 

FOR  the  treatment  of  any  class  of  the  sick  these  fundamental 
provisions  are  required:  sanitary  housing,  good  food,  good 
clothing,  skill,  kindliness  and  appreciation  of  the  aims  of  the 
hospital  on  the  part  of  all  those  charged  in  any  way  with  the  care 
or  supervision  of  patients.  These  fundamental  provisions  must 
be  made  effective  by  a  sound  administrative  system,  free  from 
political  or  other  selfish  control,  in  which  the  medical  and  scientific 
purposes  of  the  hospital  are  primary  considerations.  With  these 
provisions  constituting  the  absolutely  essential  ground  work  for 
the  treatment  of  any  class  of  the  sick,  the  following  may  be  stated 
to  constitute  the  facilities  needed  for  the  modern  treatment  of 
mental  diseases  in  a  public  institution  for  the  insane : 

1.  Direction  of  the  administration  of  the  hospital  and  leader- 
ship in  its  medical  work  by  a  physician  trained  in  the  diag- 
nosis and  treatment  of  mental  diseases. 

2.  An  adequate  medical  staff,  organized  so  that  duties  are  divided 
in  accordance  with  the  training  of  its  different  members  and 
with  the  requirements  of  the  clinical  work. 

3.  Regular  and  frequent  conferences  of  the  medical  staff  at 
which  the  diagnosis,  treatment  and  prognosis  of  each  new 
case  admitted  are  considered  and  at  which  cases  about  to  be 
discharged  are  presented,  training  in  psychiatry  for  new 
members  of  the  staff  being  considered  a  special  object. 

4.  The  reception  of  all  new  cases  in  a  special  department  or  in 
special  wards  where  they  may  receive  careful  individual  study 
and  where  those  with  recoverable  psychoses  may  receive  con- 
tinuous individual  treatment. 

5.  Classification  of  all  patients  with  reference  to  their  special 
needs  and  their  clinical  condition,  such  classification  being 
flexible  enough  to  permit  frequent  changes. 

6.  A  system  of  clinical  records  which  permits  study  and  review 
of  the  history  of  cases  even  after  they  have  been  discharged. 

7.  A  laboratory  in  which  some  of  the  more  useful  tests  required 
for  the  study  and  diagnosis  of  mental  diseases  as  well  as  for 

101 


102  MENTAL  DISEASES  AND  WAR  NEUROSES 

those  required  in  general  clinical  diagnosis  can  be  made  and 
in  which  pathological  material  can  be  studied. 

8.  Provision  for  special  treatment  such  as  hydrotherapy  and 
electrotherapy. 

9.  Provision  for  examination  and  treatment  by  dentists,  opthal- 
mologists,  gynecologists,  and  other  specialists. 

10.  An  adequate  number  of  trained  nurses  and  the  maintenance 
of  a  school  for  nurses,  under  the  direction  of  a  supervisor  of 
nurses  who  should  have  not  only  training  in  general  niu-sing 
but  special  training  in  nursing  patients  with  mental  diseases. 

11.  The  employment  of  female  nurses  in  the  reception  and  infirm- 
ary wards  for  men. 

12.  The  systematic  use  of  occupations,  for  their  therapeutic  effects 
under  the  direction  of  workers  specially  trained  for  this  duty. 

13.  Special  attention  to  recreation  and  diversion,  with  reference 
to  their  therapeutic  value. 

14.  Liberal  use  of  parole  especially  for  quiet,  chronic  patients  who 
can  live  in  farmhouses. 

15.  Special  provision  for  the  tuberculous. 


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